POSITION SUMMARY: The Prior Authorization RN is responsible for reviewing and processing medical prior authorization requests to ensure services are medically necessary, meet evidence-based guidelines, and align with the health plan’s policies. This RN plays a critical role in supporting cost-effective care while ensuring quality and compliance in alignment with regulatory and accreditation standards.
CORE FUNCTIONS
1. Manages health Plan consumer/beneficiaries across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.
2. Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.
3. Works collaboratively with both internal and external customers in assisting health Plan consumers/beneficiaries and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.
4. Performs transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient-related activities in the correct medical record.
5. Evaluates the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiary outcomes. Identifies issues that may delay patient services and refers to case management, when indicated, to facilitate resolution of these issues, pre-service, concurrently, and post-service.
6. Provides ongoing education to internal and external stakeholders who play a critical role in the continuum of care model. Training topics consist of population health management, evidence-based practices, and all other topics that impact medical management functions.
7. Identifies and refers requests for services to the appropriate Medical Director and/or other physician clinical peer when guidelines are not clearly met. Conducts call rotation for the health plan, as well as departmental call rotation for holidays.
8. Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description, authorization requirements, and all applicable federal, state, and commercial criteria, such as CMS, MCG, and Hayes.
Minimum Qualifications:
...while doing the most important work of your career. About the team The Risk Operations team is looking for an experienced fraud analyst to join an industry leading global fraud operations team. This position is responsible for writing and maintaining fraud...
...contracts. We are expanding our outreach team and seeking motivated Appointment Setters to connect with businesses in the construction... ...and goal-driven. Reliable internet, computer, and ability to work independently as a contractor. Compensation Range Expected...
...assist with divorce or parenting plans.Training is offered on a yearly basis. Conciliators are trained volunteers.Provides coaching, mediation, conciliation, facilitation and conflict-resolution services to Bellevue residents.Services do not include divorce mediation.#J-...
...Job Description Job Description &##128640; Launch Your Career in Finance Become a Loan Officer Today! Are you ready to turn ambition into success? Join our Scottsdale team as a Loan Officer and kickstart a high-income career with hands-on training, expert mentorship...
...advancement ~ Parental leave ~ Training & development ~ Tuition assistance ~ Vision insurance Job Summary You will be involved... ...environment. We are looking for an energetic Assistant Teacher to join our team! You will be assisting the head teacher with...