Prior Authorization Nurse

2 weeks ago

Texarkana, United States Genesis PrimeCare Full time

The purpose of the prior authorization nurse is to provide timely review of authorization requests and ensure the requests meet national standards and contractual requirements. The prior authorization nurse will also promote the quality and cost effectiveness of patient care using clinical acumen. Additionally, the nurse will prepare documentation, perform audits of patient records, and assist management as needed.

Duties and Responsibilities

The Prior Authorization Nurse performs the following duties as assigned.

  • Perform clinical reviews of authorization requests using appropriate criteria
  • Provide accurate and complete documentation with rationale used to approve request
  • Collaborate with various staff within provider networks and case management team coordinate patient care
  • Ability to multitask between computer and multi-line phone requests
  • Participate in interdepartmental projects when needed
  • Enter and maintain clinical information in multiple health management systems
  • Ensures patients have been cleared for specialty services, as required by provider/insurance.
  • Resolves pre-certification, registration and case-related concerns prior to a patient’s appointment.
  • Gathers pertinent information from insurance carriers, financial counselors, and other staff to make certain the patient's financial obligations for services provided.
  • Acts as a liaison between hospitals, physicians, health plans, vendors, and patients, or other referral sources.
  • Verifies insurance coverage and obtains authorizations if needed from insurance coverage.
  • Accurately enters referrals and documents communications, actions, and other data in an information system.
  • Verifies insurance benefits and obtains necessary information needed.
  • Communicates effectively with patients, physicians, providers and others.
  • Demonstrates accurate judgment.
  • Notify supervisor of any problems, in a timely manner and works to resolve said issues.
2. Fulfills administrative duties.
  • Assists in maintaining an efficient, safe, secure, orderly, and aseptic environment of care for all patients and employees.
  • Is familiar with and abides by OSHA Standards, Hazardous Materials, Universal Precautions, use of personal protective equipment, Evacuation, Fire, Disaster, and Safety Plans.
  • If bilingual, translates in Spanish between non-Spanish speaking staff and Spanish speaking patients as requested.
3. Provides clinical services.
  • Maintains clinical expertise and competency (to include age specific competency) as well as demonstrates thorough knowledge of procedures to deliver quality primary health care.
  • Documents delivery of health care and nursing process in accordance with the Clinic’s policies and procedures in a timely, accurate, and consistent manner.
  • Educates the patient and family/significant others about diagnosis and the plan of care. Acts as a resource for facilitating communication when necessary.
  • Acts as a resource within the clinic to other staff members in regards to patient care.
  • Participates as a team member and promotes teamwork by assisting others with patient care and department activities.
4. Performs all other duties as assigned.

Knowledge, Skills and Abilities

Required
  • Knowledge of basic principles of health promotion, prevention and motivation
  • Knowledge of protocols in general and an ability to quickly gain specific knowledge of the Clinic’s current operational protocols
  • Knowledge of medical terminology and appropriate abbreviations
  • Demonstrates knowledge of the Texas Nursing Practice Act
  • Ability to read and comprehend medical instructions, short correspondence, and memos
  • Ability to document, with clarity, all information relevant to a patient’s needs
  • Ability to effectively present information in small group situations to patients, Clinic staff, and the general public. Ability to prepare statistical and administrative reports
  • Ability to work cooperatively with community agency personnel to coordinate services for patients
  • Ability to use a glucometer and interpret the results
  • Ability to use office equipment including but not limited to computers, fax machines, telephones and copiers
  • Ability to prioritize and allocate resources
Preferred
  • Spanish speaking and writing skills
Credentials and Experience

Required
  • Licensed Vocational Nurse degree from an accredited school of nursing.
  • Current unrestricted license from the state of Texas Board of Nursing
  • Current Cardiopulmonary Resuscitation (CPR) for Healthcare Professionals
  • Knowledge of utilization management and case management principles preferred
  • Prior authorization experience preferred
  • Advanced verbal, written communication, and organization skills
  • Knowledge of Microsoft word
  • Strong service orientation and professionalism
Preferred
  • One (1) year of practice experience as an LVN giving direct patient care

Special Requirements

The employee must be able to lift and/or move more than 50 pounds. Requires full range of body motion including handling and lifting patients, manual and finger dexterity and eye/hand coordination. Requires sitting, standing and walking for extensive periods of time. Requires working under stressful conditions or working irregular hours. Requires frequent exposure to communicable diseases, body fluids, toxic substances, medicinal preparations and other conditions common to a clinic environment. The employee frequently is required to reach with hands and arms. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Ability to work with a moderate noise level in the work environment is required. Ability to handle significant stress.

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