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Job Description:
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
Knowledge, Skills and Abilities:
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
Qualifications:
RN with valid license in good standing
3-5 years clinical nursing experience required
Previous utilization management, case management or discharge planning experience preferred
Experience with Microsoft Excel and Microsoft Teams (preferred)
Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures.
Salary Range:
$63,502.40 -$90,719.20