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Clinical Pre-Service Nurse Auditor

5 months ago

Houston, United States Premier Medical Resources Full time
Job DescriptionJob Description

Premier Medical Resources is a healthcare management company headquartered in Northwest Houston, Texas. At Premier Medical Resources, our goal is to leverage and combine the expertise and skillset of our employees to drive quality in all we do. Our goal is to create career pathways for our employees just starting their professional career, and to those who seek to bring their expertise and leadership as we strive to combine best practices and industry excellence. Come join our team at Premier Medical Resources where passion and career meet.

Premier Medical Resources is hiring a full-time Clinical Pre-Service Nurse Auditor (LVN). The Clinical Pre-Service Auditor will provide/confirm precertification of and all authorization requests. The Clinical Pre-Service Auditor will assist with minimizing denials by way of ensuring medical criteria / medical necessity is met prior to services are scheduled. This process includes clinical judgement, utilization management, application, understanding of payor protocols requirements, and verification of medical necessity utilizing nationally recognized criteria.


ESSENTIAL FUNCTIONS:

• Works as part of integrated team and is involved in reviews of authorization requests and communicates with the physicians and clinic when additional information is needed.
• Performs activities that include obtaining payer authorization for outpatient services that require
notification/authorization based on payer specific guidelines.
• Maintains a thorough understanding of the plan's provider contracts, authorization requirements and ongoing follow-up and re-evaluation of clinical departments/areas as requested or needed for authorization review.
• Compiles and maintains established payer protocols to determine the medical appropriateness of ordered pre and post scheduled services.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Familiar with hospital coding and billing processes.
• Knowledge of InterQual/Milliman guidelines, Medicare guidelines
• Above average verbal and written communication skills
• Other Skills: Analytical, Mathematics, Medical Terms
• Must be able to interact successfully in a culturally diverse environment

EDUCATION AND EXPERIENCE:

• Nurse in good standing, currently licensed in the State of Texas without stipulations in practice as a Licensed Vocational Nurse
• Three (3) years of hospital experience in various clinical areas.
• One (1) year utilization review, authorization, or case management experience

BENEFITS:

  • 3 Medical Plans
  • 2 Dental Plans
  • 2 Vision Plans
  • Employee Assistant Program
  • Short- and Long-Term Disability Insurance
  • Accidental Death & Dismemberment Plan
  • 401(k) with a 2-year vesting
  • PTO + Holidays

Please visit our website for more information:

www.pmr-healthcare.com

Compensation to be determined by the education, experience, knowledge, skills, and abilities of the applicant, internal equity, and alignment with market data.



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