Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage.
Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Walk me through the day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):
Clinical review and documentation of medical request for prior authorization of medically necessary services, sitting in front of a computer for 8 hours with allowance for breaks and 1 hour lunch, biweekly team huddles (virtual), and attention to emailed team instructions, proficient in toggling between multiple systems.
Describe the performance expectations/metrics for this individual and their team:
Quality documentation, timely processing of up to 18 authorizations per day on average, team player with positive attitude
Tell Me About What Their First Day Looks Like
Getting systems set up and in working order, verifying that all systems are ready for training and production, getting to know the team lead (Sr. PA Nurse) and the daily expectations, shadowing to understand the daily look and feel of the work for the first week along with corporate new hire learning journey.
Education/Experience
Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing or Associates and 2 – 4 years of related experience.
Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification
LPN - Licensed Practical Nurse - State Licensure required.
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member.
Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
Provides feedback on opportunities to improve the authorization review process for members.
Performs other duties as assigned.
Complies with all policies and standards.
Seniority level
Entry level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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