Prior Authorization Nurse - Remote - AZ

Blue Cross Blue Shield of Arizona•Phoenix, AZ

1d•Remote

About The Position

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, the company has a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Positions are classified as hybrid, onsite or remote. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. The purpose of the job is to ensure accuracy and timeliness in the completion of prior authorization (PA) requests to meet contractual requirements and ensures all reviews utilize nationally recognized and evidence-based standards for the Medicaid Segment which includes Medicaid and Medicare Advantage / Dual Eligible Special Needs Plan (D-SNP), and Affordable Care Act (ACA) members. It also ensures the completion, accuracy, and timeliness in the Notice of Action (NOA) process.

Requirements

3 years of clinical experience
1 year of Medicaid/Medicare experience
1 year prior authorization and member and provider notification (NOA) experience
1 year experience with National Committee for Quality Assurance (NCQA) standards
Associate degree in Nursing
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN or LPN.

Nice To Haves

3+ years of experience in managed care
3+years of experience in prior authorization/utilization review
Bachelor of Science in Nursing

Responsibilities

Ensures the accuracy and timeliness of prior authorization requests to meet contractual requirements.
Coordinates and manages the established preauthorization review process for pre-service requests.
Ensures the use of nationally recognized and evidence-based standards in the completion of all pre-service reviews.
Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request(s) to the medical director for determination when criteria not met.
Clearly define and document review rationale to support approval, Medical Director Review and/or Notice of Action document.
Initiates interdepartmental coordination to ensure quality and timely care for members.
Participates in Quality Improvement Projects as directed.
Participate in department audits and other regulatory activities.
Engage cross-functionally and participate in special projects as needed.
Performs Notice of Action (NOA) process.
Participate in annual policy and procedure review and revision.
Perform all other duties as assigned.