Prior Authorization Nurse- 226437

2 weeks ago


Los Angeles CA United States Medix™ Full time

Medix is hiring a direct hire Prior Authorization LVN or RN with a great Healthplan in Chatsworth, CA

Please note this position is 100% remote, but training must be onsite in Chatsworth, CA, there are

no exceptions for remote training. (training typically is 2-3 weeks)

Location: Chatsworth California 91311 United States

Schedule: Monday-Friday 8:30am-5p

Average salary is: 65k-100K- we can talk through pay and what negotiating might look like

Summary of Position:

  • The UM Prior Authorization Nurse is primarily responsible for reviewing referrals for medical
  • services to determine medical necessity and course of action, by using their independent
  • judgment and extensive knowledge of medicine, along with clinical guidelines. The UM Prior Authorization Nurse confers with Nursing Manager, VP of Clinical Policy and/or Medical Director whenever appropriate in utilization management or problem solving.

Essential Duties

  • Reviews prior authorization referrals for medical necessity by:
  • Exercising independent judgment and extensive knowledge of medicine.
  • Independently reviewing and assessing records provided and determining how patient specifically meets criteria for services being requested.
  • Ensuring all health plan, state and clinical guidelines are enforced in making
  • of decision.

Approval Recommendations

  • Developing clinical summary for why patient specifically meets criteria for services requested.
  • Independently making decision to approve services requested.
  • Denial Recommendations
  • Developing clinical summary for why information provided does not show
  • patient meeting criteria for services requested.
  • Making recommendations for Medical Director’s review based on assessment
  • of why information provided does not support patient meeting criteria for
  • services requested.

Qualifications/Experience

  • Bachelor’s or Associate Degree in Nursing (Bachelor’s preferred)
  • Current CA State licensure as Registered Nurse (RN) or Licensed Vocational Nurse (LVN)
  • At least 2 years of experience in a comparable position.
  • Prior authorization or Managed Care experience preferred.

Skills

  • Ownership/Dependability - Assumes responsibility for the accomplishment of goals
  • and objectives by accepting ownership of assignments, adhering to established work
  • schedules, practicing efficient time management to meet quality service goals and
  • support team objectives. Willingness to be held accountable for errors.
  • Attendance – Due to the nature of the department, must maintain excellent
  • attendance and dependability.
  • Attention to Detail – Must have ability to pay close attention to all details in medical records and clinical guidelines.

Job Description

  • Business Acumen - Professionally represents Company in appearance and ability to display a professional and positive approach to a job.
  • Physical Demands/Work Environment
  • Must be able to work in a seated position for long periods of time
  • Must be able to use fingers, hands and arms at computer keyboard for long periods of time


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