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Prior Authorization Nurse
3 months ago
**Position Summary**:
**Essential Duties and Responsibilities include the following**:
- Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
- Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues.
- Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management.
- Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
- When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
- Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies.
- Maintain regulatory Turnaround Time Standards per regulatory guidelines.
- Document accurately and completely all necessary information in authorization notes.
- Approve those approvable requests as indicated based on protocols.
- Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation.
- For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed.
- When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
- Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
- Participates in “service recovery” through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
- Identifies network needs and report to management for potential contracting opportunities.
- All other duties as directed by management.
**Organizational Responsibilities**:
- Proactively support and practice company mission, vision and values.
- Follow Employee Handbook guidelines and company policies and procedures.
- Follow established departmental dress code.
- Appropriately and accurately maintain time keeping records.
- Adhere to attendance policy and time off requests.
- Follow safety policies and procedures.
- Be flexible and adaptable and courteous and promote professionalism.
- Communicate verbally and in writing through appropriate channels.
- Maintain confidentiality at all times in compliance with company policy and HIPAA requirements.
- Employee has completed all required annual Compliance training and signed attestation form is attached for each module.
The pay range for this position at commencement of employment is expected to be between $37.50 - $40.00 per hour however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
**Full Time Position Benefits**:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our emp
