Prior Authorization RN Lead

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 3,500 providers including Primary Care, Specialty, Hospital System and ancillary provider partnerships. We have operated in the Arizona market for more than 10 years, and are based in Chandler, Arizona. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

The Prior Authorization RN Lead is responsible for ensuring AZPC policies and procedures and regulatory guidelines are followed and met. Through daily support of clinical nurse operations and participation in day-to-day activities, guides clinical staff to provide outstanding customer service, are knowledgeable, and have the ability to assist in the coordination of care that meet or exceed the organization’s expectations. The Prior Auth RN Lead works closely with the PA supervisor, PA staff, and Directors to maintain turnaround time requirements of the contracted Health Plan(s) and internal targets. Routinely interacts with physicians, their office staff, and internal customers.

POSITION DUTIES & RESPONSIBILITES

• Manages nurse workflow as directed by prior auth management to ensure that turnaround times are compliant with regulatory and health plan requirements.
• Performs all duties of the PA Nurse with an accuracy rate of 99% to produce quality work.
• Acts as point of contact for peers for clinical prior authorization questions, understanding when to escalate to upper management.
• Conducts annual reviews (at minimum) on PA Nurse related Standard Operating Procedures.
• Performs monthly internal audits of prior authorization nurse staff to ensure quality of work being completed and provides findings to Directors.
• Collaborates in new hire and ongoing training, coaching, and mentoring of PA Nurses on customer service standards, AZPC policies and procedures.
• Collaborates with prior authorization management to create, modify, and implement training programs for clinical staff to stay current on changes.
• Performs semi-annual review of under/over utilization management.
• Assists in Health Plan Reporting preparation, submission, and communications monthly, quarterly, or annually.
• Assist in Health Plan and NCQA audit preparation, as needed.
• Assist in work plan and reports preparation for UMC quarterly.
• Anticipates our customer needs: Understand the wants and needs of all customers, listen for cues and identify how to respond and intervene as needed.
• Demonstrates the ability to follow through with requests, sharing of critical information and getting back to management, providers, and other individuals in a timely manner.
• Demonstrates honesty and integrity in everyday activities.
• Protects privacy for patients, providers and employees; ensures all personal health information is kept confidential.
• Interacts professionally and communicates clearly with staff, other departments, management, providers and members.
• Other duties as assigned by the prior authorization management.

EDUCATION, TRAINING AND EXPERIENCE

• Graduated from an accredited Registered Nurse Program.
• Current unrestricted AZ RN License.
• Minimum of 3 years acute care of care management experience.
• Minimum of 2 years prior authorization experience with demonstrated excellent communication, attention to detail, and problem-solving skills.
• Minimum of 2 years in a leadership type role (any level).
• Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
• Strong knowledge of Continuum of Care, Care planning, Transitions of Care and Inner-disciplinary Care Team structures and functionality.
• Prior experience with record review and knowledge of record documentation standards.
• Exceedingly detail-oriented, able to function under pressure and prioritize and re-prioritize tasks as needed.
• Exceptional organizational and project management skills including strong attention to accuracy.
• Exceptional interpersonal, verbal and written communication skills, including proofreading and grammar skills.
• Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
• Ability to work both independently and as part of a team, with minimal supervision.
• Proficient ability with multiple Microsoft applications (Outlook, Word, Excel, PowerPoint, etc.) and work within electronic health records systems.

*This is a hybrid position, effective after first 90 days of mandatory in-office training*