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Prior Authorization Registered Nurse
2 months ago
Position Overview: The Registered Nurse in the Prior Authorization role is tasked with evaluating proposed inpatient, outpatient, and home care treatment plans to ensure they meet medical necessity and efficiency standards as per CMS coverage guidelines. This role involves working under the supervision of an RN or MD, while maintaining a self-directed work approach.
Key Responsibilities:
- Conduct utilization review activities, including pre-certification, concurrent, and retrospective assessments in line with established guidelines.
- Assess the medical necessity of treatment requests by applying relevant medical criteria during initial reviews and utilizing evidence-based guidelines.
- Employ critical thinking and decision-making skills to determine coverage for necessary healthcare services.
- Manage Utilization Management calls professionally and competently.
- Refer cases to a review physician when treatment requests do not align with necessity guidelines or when guidelines are unavailable, ensuring timely communication.
- Document and communicate all utilization review activities, including calls and demographic information, and send appropriate system-generated correspondence to providers and members.
- Provide mentorship and guidance to fellow utilization review nurses and assist in onboarding new team members.
- Identify and escalate potential quality issues to the Clinical Quality Management Department and report suspected fraud cases to the Compliance Department.
- Engage in rate negotiations with non-network providers, applying suitable reimbursement methodologies.
- Maintain accurate documentation of rate negotiations for proper claims processing.
- Identify and refer cases to Disease Management and Case Management as necessary.
- Perform additional related duties as assigned.
Qualifications:
- Current, unrestricted Texas RN license or compact license.
- Minimum of 2 years of experience in managed care or 5 years of nursing experience.
- Proficient in PC software and computer skills.
- Experience in authorization processes.
- Background in telephonic or telecommute roles.
- Familiarity with Utilization Review/Management.
- Knowledge of ICD-10 and CPT coding.
- Experience with InterQual or Milliman guidelines.
- Strong verbal and written communication skills.
- Proven problem-solving and analytical abilities.
- Ability to collaborate effectively with multidisciplinary teams.
Workplace Policy: UnitedHealth Group maintains a drug-free workplace. Candidates will be required to pass a drug test prior to employment.
