- Summary of Position:
The UM Prior Authorization Nurse is primarily responsible for reviewing referrals for medical
services to determine medical necessity and course of action, by using their independent
judgment and extensive knowledge of medicine, along with clinical guidelines. The UM Prior Authorization Nurse confers with Nursing Manager, VP of Clinical Policy and/or Medical Director whenever appropriate in utilization management or problem solving.
Essential Duties
Reviews prior authorization referrals for medical necessity by:
Exercising independent judgment and extensive knowledge of medicine.
Independently reviewing and assessing records provided and determining how patient specifically meets criteria for services being requested.
Ensuring all health plan, state and clinical guidelines are enforced in making
of decision.
Approval Recommendations
Developing clinical summary for why patient specifically meets criteria for services requested.
Independently making decision to approve services requested.
Denial Recommendations
Developing clinical summary for why information provided does not show
patient meeting criteria for services requested.
Making recommendations for Medical Director's review based on assessment
of why information provided does not support patient meeting criteria for
services requested.
Qualifications/Experience
Bachelor's or Associate Degree in Nursing (Bachelor's preferred)
Current CA State licensure as Registered Nurse (RN) or Licensed Vocational Nurse (LVN)
At least 2 years of experience in a comparable position.
Prior authorization or Managed Care experience preferred.
Skills Ownership/Dependability - Assumes responsibility for the accomplishment of goals
and objectives by accepting ownership of assignments, adhering to established work
schedules, practicing efficient time management to meet quality service goals and
support team objectives. Willingness to be held accountable for errors.
Attendance - Due to the nature of the department, must maintain excellent
attendance and dependability. -
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Prior Authorization Nurse - Chatsworth, CA, United States - Medix
Description
Medix is Hiring a direct hire Prior Authorization LVN or RN with a great Healthplan in Los AngelesPlease note this position is 100% remote, but training must be onsite in Chatsworth, CA, there are no exceptions for remote training. (training typically is 2-3 weeks)
Location: Chatsworth California 91311 United States
Schedule: Monday-Friday 8:30am-5p
Average salary is: 89k-100K- we can talk through pay and what negotiating might look like
records and clinical guidelines.
Job Description
Business Acumen - Professionally represents Company in appearance and ability to
display a professional and positive approach to a job.
Physical Demands/Work Environment
Must be able to work in a seated position for long periods of time
Must be able to use fingers, hands and arms at computer keyboard for long periods of
time
#MedixWest
