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):
Behavioral Health and Psychiatric Exp required!
Reading treatment plans and making determinations
Must have experience with all ages (pediatrics to geriatrics)
Coordinate with providers via email and phone
Experience as a Review Nurse (remotely)
Experience with Prior auth
Would accept an RN with Behavioral/Mental and Psychiatric health experience or would accept a Licensed Social Worker/Licensed Professional Counselor
Navigating multiple systems
Reviewing Medical Records
Education/Experience
Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing 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
Registered Nuse or Social Worker/ Counselor Requires a master’s degree and AZ license
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Responsibilities
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
Contract
Job function
Health Care Provider
Industries
Staffing and Recruiting
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