Prior Authorization Nurse
Location: Phoenix Arizona
Description: Care1st Health Plan Arizona. Inc. is looking of Prior Authorization Nurse right now, this occupation will be placed in Arizona. For detail informations about this occupation opportunity please give attention to these descriptions. GENERAL SUMMARY:
This Prior Authorization Nurse conducts prospective review of authorization requests including selected specialties, medical treatments an! d services, elective hospital admissions, ancillary services, home care and out of area referrals. The nurse makes clinical decisions based on established criteria and regulatory requirements. Prepares documentation and presents prior authorization requests to the Medical Director for additional review. This position works closely with the NOA coordinator to develop/review denial letters.
QUALIFICATIONS:
RN/LPN with current License in state of Arizona
Minimum of three (3) years of experience with hospital/provider office nursing
Minimum of three (3) years experience in Managed Care
Previous Prior Authorization experience preferred
Excellent verbal and written communication skills
Excellent organizational skills
Knowledge of AHCCCS and Medicare regulations
Knowledge of Milliman guidelines
Knowledge of CRS
Computer literate (proficient in MS Office, Excel, Word)
Team player with excellent attitude
Strong service ! orientation and professionalism
ESSENTIAL DUTIES A! ND RESPONSIBILITIES:
Perform prior authorization process by performing clinical review of requests requiring medical review and entering authorizations into the system.
Provides clear and accurate documentation on rational for approving request or reason for sending to the Medical Director for additional review.
Handle telephone requests timely and accurately.
Develop and update health plan resources and forms to assist staff in their day to day functions. Provide resources and training to prior authorization technicians upon completion.
Assist Case Management and Concurrent Review staff with complex cases.
Assist with the design and updating of PA grids and desktop processes.
Assist in reviewing and making revisions to department policies to assure compliance with regulatory agencies.
Participate in interdepartmental projects as needed.
CORPORATE INTEGRITY:
Understands and abides by all departmental policies and proce! dures as well as the organizations Corporate Integrity Program.
We do not specifically reward practitioners or other individuals for issuing denials of coverage of service or care.
Financial incentives for MM decision makers do not encourage decisions that result in underutilization.
Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.
MM decision making is based only on appropriateness of care and service and existence of coverage.
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If you were eligible to this occupation, please email us your resume, with salary r! equirements and a resume to Care1st Health Plan Arizona. Inc..
If you interested on this occupation just click on the Apply button, you will be redirected to the official website
This occupation starts available on: Wed, 11 Sep 2013 09:24:44 GMT