Job Title* Outpatient Prior Authorization Nurse

JOB TITLE: Outpatient Prior Authorization Nurse FLSA STATUS: Non-Exempt

DEPARTMENT: UM

REPORTS TO: Sr. Director UM-RN

JOB SUMMARY: Responsible to provide timely review of authorization requests meet national standards and contractual requirements. The prior authorization nurse will promote the quality and cost effectiveness of patient care using clinical acumen.

ESSENTIAL JOB FUNCTIONS:

1. Perform timely review of prior authorization requests for medical necessity by applying appropriate clinical criteria.
2. Provide accurate and complete documentation with rationale used to approve requests.
3. Collaborate with various staff within clinical services to coordinate patient care.
4. Provide appropriate interventions which demonstrate knowledge and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Use interpreter services as needed.
5. Enter and maintain clinical information in authorization systems.
6. Prepare case summaries and provide clinical criteria for cases that require MD reviews.
7. Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.
8. Maintains regular and consistent attendance.
9. Adheres to Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS:

1. Takes on special projects as needed.

1. Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

1. Continuous Learning:

a. Attends staff meetings as required.

b. Attends appropriate training, seminars and workshops as required

2. Customer Focus:

a. Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and relations with Supervisor, co-workers and other staff.

3. Quality/Process Improvement/Safety

a. Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulators

standards set forth by governing entities.

POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

• High school graduate or equivalent.
• Minimum 1 year clinical nursing setting experience
• Prior authorization experience preferred

SKILLS/KNOWLEDGE/ABILITY:

• Knowledge of utilization management principles
• Prior authorization experience preferred
• Familiarity with Medi-Cal and Medicare guidelines
  • Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to residents and staff.
  • Willingness and ability to follow written and verbal direction in English.
  • Willingness and ability to maintain appropriate level of confidentiality and privacy.
  • Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.
  • Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.
  • Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.
  • Ability to effectively prioritize items/tasks as required.
  • Willingness and ability to take initiative and be a self-starter.
  • Willingness and ability to understand and comply with Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING:

• Active/Current, Unrestricted RN or LVN CA license from an accredited school of nursing.