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The Prior Authorization Review Nurse evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, outpatient services and out of network providers. Reviews medical records, uses clinical expertise and compares information to established guidelines and the members benefit plan. Works closely with departmental management staff to impact the treatment plan and identify treatment plan alternatives.
Essential Functions:
- Utilizes Well Care designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with review determinations.
- Evaluates all requests for service, to determine the Company's financial liability including the collection of information regarding subrogation and COB and entry in the Health Services system.
- Ensures accurate coding using CPT-4 and ICD-9 codes. Documents all information accurately.
- Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
- Adheres to all confidentiality requirements.
- Applies appropriate benefits information to determine if requested services are a covered benefit.
- Applies medical knowledge and experience to authorize pre-service requests.
- Arranges for transfer to in-network care when appropriate.
- Initiates process for Letter of Agreements for out of network provider requests that meet approval criteria.
- Identifies cases appropriate for case management and makes appropriate referrals.
- Identifies potential quality of care issues and refers to the Quality Department.
- Meets service standards for decision turn around times and written correspondence
- Performs special projects as assigned.
Education/Experience:
- Licensed Practial Nurse.
- A Bachelor's Degree in Health Services or nursing preferred.
- 2-4 years clinical experience in an acute care facility. Managed care experience preferred.
- Previous experience working with treatment teams to meet the healthcare needs of participants.
- Knowledge of community, state and federal laws and resources.
Licenses/Certifications:
- Licensed Practial Nurse with current unrestricted license
Knowledge, Skills, Abilities Required:
- Ability to review and interpret treatment plans.
- Ability to define problems, collect and interpret data, establish facts, draw valid conclusions and process work to completion
Computer Skills:
- Knowledge of Microsoft Office including Outlook, Word and Excel
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