Prior Authorization Nurse

The Hospital Authority of Miller County•Colquitt, GA

About The Position

The Prior Authorization Nurse provides timely review of authorization requests to ensure they meet national standards, contractual requirements, regulations, and the obligations of all parties involved. The nurse uses clinical judgment to promote quality and cost-effective care by reviewing medical records and related documentation, collecting evidence and patient information, and communicating with insurance providers when additional information is needed. The role may involve coordinating with administrators and healthcare providers to help ensure patients receive authorized care. The position also assists the clinical team with direct patient care, designated independent procedures, and nursing tasks as needed. Under the supervision of a registered nurse, physician, physician assistant, or nurse practitioner, the nurse provides care addressing patients’ psychosocial, physical, and general needs; communicates with patients, families, physicians, and team members; and performs care within professional, regulatory, nursing, and clinic standards.

Requirements

Current LPN licensure in the State of Georgia.
Active American Heart Association BLS certification within 30 days of hire.

Nice To Haves

Experience performing prior authorizations.

Responsibilities

Review authorization requests promptly and ensure they meet national standards and contractual requirements.
Review medical records and related documents, collect evidence and patient information, and communicate with insurance providers to obtain additional information when needed.
Ensure authorization decisions meet applicable regulations, requirements, and contractual obligations.
Coordinate with administrators and healthcare providers to gather necessary information and support patients receiving authorized care.
Assist the clinical team with direct patient care, designated independent procedures, and nursing tasks as needed.
Provide direct patient care under the supervision of a physician, physician assistant, or nurse practitioner; evaluate outcomes, consult with other health team members, and adjust nursing care as indicated.
Perform head-to-toe assessments, as permitted by policy and under supervision, for patients across age groups, including neonates, pediatric, adolescent, and geriatric patients.
Assess and reassess pain, use appropriate pain-management techniques, and educate patients and families about pain management.
Provide care that promotes patient safety and reduces the likelihood of medical or healthcare errors.
Provide age-appropriate care based on knowledge of growth and development and patients’ age-specific needs.
Maintain current knowledge of medications and their correct administration based on patient age and clinical condition.
Use medical and surgical asepsis during treatments and special procedures.
Assist physicians with procedures and perform services requiring technical and manual skills under the direction of a physician, physician assistant, or nurse practitioner.
Revise plans of care as indicated by patient response to treatment and provide care within the level of licensure.
Meet current documentation standards and policies.
Demonstrate knowledge of laboratory requirements and requisitions.
Maintain regulatory requirements and nursing and office/clinic policies, procedures, and standards.
Communicate patients’ clinical conditions, including diagnostic study results and symptoms, to physicians and team members.