Prior Authorization Nurse

Sacramento, CA 94203

Post Date: 02/05/2018 Job ID: 25857 Category: Registered Nurse

Job Description:
  • Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
  • Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations.
  • Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.
  • Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care.
  • Educate providers on utilization and medical management processes.
  • Provide clinical knowledge and act as a clinical resource to non-clinical team staff.
  • Enter and maintain pertinent clinical information in various medical management systems.
  • Interact with providers to educate and direct care to participating network providers.
  • Participate in utilization management committees and work on special projects related to utilization management as needed.

Qualifications:
  • Current State LPN/LVN or RN License.
  • Graduate from an Accredited School of Nursing.
  • Bachelor s degree in Nursing preferred.
  • 2+ years of clinical nursing experience.
  • 1+ years of utilization management experience in a managed care setting.
  • Knowledge of utilization management principles and healthcare managed care.
  • Experience with medical decision support tools (i.E. Interqual, NCCN) and government sponsored managed care programs.

For more information, please contact our office at 877-782-3334.

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