RN Prior Authorization Nurse Healthcare Compact Lics
About the positionResponsibilities• Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services• Answers Utilization Management directed telephone calls; managing them in a professional and competent manner• Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information• May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses• Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department• Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies• Documents rate negotiation accurately for proper claims adjudication• Identify and refer potential cases to Disease Management and Case Management• Performs all other related duties as assignedRequirements• Current, unrestricted Texas RN license or compact license• 2+ years of experience in managed care OR 5+ years of nursing experience• Proficient in PC Software computer skillsNice-to-haves• Authorization experience• Telephonic and/or telecommute experience• Utilization Review/Management experience• ICD-10, CPT coding knowledge experience• InterQual or Milliman knowledge/experience• Proven excellent communication skills both verbal and written skills• Proven solid problem solving and analytical skills• Proven ability to interact productively with individuals and with multidisciplinary teams with minimal guidanceBenefits• Comprehensive benefits package• Incentive and recognition programs• Equity stock purchase• 401k contribution Apply tot his job