Prior Authorization Nurse (50462)

GLOBALHEALTH HOLDINGS LLC • Oklahoma City, OK

26d • Remote

About The Position

This position performs utilization management review. This position determines appropriateness of services, medical necessity, and location of services required to encourage effective, high-quality care and cost-efficient outcomes through. This position requires excellent verbal and written communication, organization and time management skills.

Requirements

• Current active LPN license in Oklahoma/Texas or compact
• Minimum of 3-5 years of clinical experience required
• Working knowledge of Microsoft software programs
• Excellent organizational skills
• Strong communication skills
• Proven ability to work independently and as a member of a team
• Must have access to a reliable and secured internet connection source.
• Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.

Nice To Haves

• Experience in managed care/utilization management preferred
• Working knowledge of ICD-10/CPT codes preferred

Responsibilities

• Reviews preservice requests, appropriateness of services, and ensure timely determination
• Communicates with customers, both internal and external, regarding status of referral/referral process.
• Utilizes NCDs, LCDs, MCG, and additional guidelines to assist in determining coverage of the request.
• Maintains current knowledge of managed care issues (benefits, contracted providers, health plan guidelines, MCG, NCD, LCD and community standards of practice and regulatory developments, and new and experimental procedures).
• Collaboration with internal team to support member needs, including but not limited to discharge planning, provider relations, and care management.
• Adheres to company and department policies and procedures.
• Performs other duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed