Prior Authorization Nurse

Regal Medical Group•San Bernardino, CA

About The Position

The Prior Authorization Review Nurse is responsible for supporting the process that manages all outpatient services. The goal of the Prior Authorization Review Nurse is to actively participate in the review of, current services being rendered and requests for service, and to follow guidelines in the approval of those services or making recommendations for other determinations to the provider reviewer in the most cost effective manner, and ensures the optimum quality of care is provided.

Requirements

Graduate from an accredited Nursing Program
Current California Nursing License
Current CPR Certification.
Minimum of 1 year acute experience
Knowledge of Healthcare and Managed Care preferred.
Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization and Quality Management.
Knowledgeable with the pre authorization process and flow.
Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
Ability to deal with responsibility with confidential matters
Ability to work in a multi-task, high stress environment

Responsibilities

Plan, research alternative and assist in the routing of member to the most appropriate IPA provider (s), ancillary providers and sites of care.
Act as liaison between the case managers, UM coordinators, contracted providers, and the members. patients, providers, and other healthcare providers.
Perform case reviews base on key screening outpatient indicators and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to community standards and health plan/ CMS guidelines.
Collaborate and communicate with all the members of health care team to coordinate the. continuum of care by devising plans for the identification of member cases incorporating inpatient and post hospitalization care.
Prepare, evaluate and report on utilization data, outcome measurement and quality an issue, based on information’s received from case review to QI supervisor.
Maintain regulatory Turnaround Time Standards per CMS (Senior) and ICE (Commercial).
Documents accurately and completely necessary information in authorization notes.
Submit authorization requests needing physician review with an accurate interpretation and recommendation.
Accurately and timely evaluates all monthly rental equipment for continued need and requests pick-up of any unnecessary equipment immediately.
Effectively manages the rental and purchase of all DME to assure the appropriate use of rental vs. purchase.
Coordinates and insures appropriate utilization of ancillary professional services, i.e. (Nurse visits, PT,OT, speech, and home based services)
Maintain patient confidentiality so that HIPAA compliance is observed at all times
Assists other staff and supports the team approach.
Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
Demonstrates honesty and integrity in every day activities.
Recognizes when an error has been made and immediately reports to appropriate manager.
Participates in “service recovery” through follow-up with an upset customer, gathering information, and demonstrates empathy.
Identify network needs and report to management for potential contracting opportunities.
Maintains quality monitors as assigned by Supervisor.
Participates in orientation, instruction/training of new personnel.
Participates in the efficient, effective, and responsible use of resources such as supplies and equipment.
Know and follow the Employee Handbook polices and procedures
Performs other duties as assigned.