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Prior Authorization Nurse- 226437
5 months ago
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
