Prior Authorizations/Referrals Nurse (FT)
The Prior Auth Nurse’s primary responsibilities are to perform the review of requests for service authorizations in order to monitor continuity and coordination of care and to assist in the utilization of appropriate services. The Prior Authorization Nurse conducts review of authorization requests including selected specialties, medical treatments and services, elective hospital admissions, rehabilitative and ancillary services, home care and out-of-plan referrals. The Prior Authorization Nurse assists with complex cases; interacts with the Prior Authorization Representatives to direct appropriate utilization and data capture; and assists with internal process development.
Current unrestricted Arizona RN/LPN license; Ability to work independently and cohesively and possess strong clinical skills; Detail oriented, able to function under pressure, and effectively multi-task; Identify and determine viability of authorizations and secure documentation to support determinations; Utilize Review Criteria to pre-screen authorization requests for medical necessity and appropriateness; Coordinate and facilitate requirements timely to ensure authorizations can be adjudicated with Medical Directors; Excellent and professional communicationn skills, verbal and written.
- Five years related experience - Knowledge of Medicare, State and local managed care regs - Strong knowledge of Continuum of Care, Care Planning, Transitions and ICT functionality - Experience with EZ Cap and NextGen preferred.
- Graduate from an accredited Nursing Program