Prior Authorization Nurse- 226437 - Los Angeles, United States - Medix™

Description

Medix is hiring a direct hire Prior Authorization LVN or RN with a great Healthplan in Chatsworth, CA

Please 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: 65k-100K- we can talk through pay and what negotiating might look like

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.
• Attention to Detail – Must have ability to pay close attention to all details in medical 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