Prior Authorization, RN

Alpine Physicians • Denver, CO

3d • Remote

About The Position

The Prior Authorization, Nurse is responsible for clinical review of requests for health care services. Essential Functions: Assesses appropriateness of service requests based on established Medicare and Health Plan standards and guidelines Evaluates the requested care needs of the PHP member using clinical judgement and critical thinking skills Supports physicians and providers in maintaining a focus on quality care enforcement for the Physician Health Partners members Participates in identifying issues related to the prior authorization process and seeks creative solutions to resolve issues Collaborates with team members to ensure incoming service requests are managed within allotted processing time and Medicare required turn-around time Identifies potential need for interdisciplinary collaboration and facilitates referrals as needed Documents service request review activity in a clear, concise, and accurate manner consistent with the internal review processing rules Maintains confidentiality and ensures compliance with HIPAA regulations Other duties as assigned

Requirements

• Strong clinical knowledge and critical thinking skills
• Knowledge of Prior Auth process, NCQA guidelines, CMS - Medicare regulations, HMO Product structure rules and referral requirements
• Excellent verbal and written communication skills
• Great customer relation skills
• Team focused with strong collaborative skills
• Independent problem-solving skills
• Self-motivated and self-managed
• Proficient in Microsoft Office Suite
• RN with valid license in good standing
• 3-5 years clinical nursing experience required
• Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures.

Nice To Haves

• Previous utilization management, case management or discharge planning experience preferred
• Experience with Microsoft Excel and Microsoft Teams (preferred)

Responsibilities

• Assesses appropriateness of service requests based on established Medicare and Health Plan standards and guidelines
• Evaluates the requested care needs of the PHP member using clinical judgement and critical thinking skills
• Supports physicians and providers in maintaining a focus on quality care enforcement for the Physician Health Partners members
• Participates in identifying issues related to the prior authorization process and seeks creative solutions to resolve issues
• Collaborates with team members to ensure incoming service requests are managed within allotted processing time and Medicare required turn-around time
• Identifies potential need for interdisciplinary collaboration and facilitates referrals as needed
• Documents service request review activity in a clear, concise, and accurate manner consistent with the internal review processing rules
• Maintains confidentiality and ensures compliance with HIPAA regulations
• Other duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 501-1,000 employees