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Prior Authorization Clinician

ICONMA

Role overview

Qualifications

  • Nursing degree or diploma required, bachelor’s degree in nursing preferred
  • RN license in state of MA, NH or compact license
  • 2+ years prior authorization experience
  • Managed care experience

Responsibilities

  • Determines medical appropriateness of inpatient and outpatient services
  • Performs utilization review activities, including pre-certification, concurrent and retrospective reviews
  • Utilizes decision-making and critical-thinking skills in the review
  • Maintains compliance with Federal, State and accreditation organizations

Key facts

Hard skills

Prior Authorization Utilization Management Medical Necessity Medicaid Managed Care Data Management Organizational Structure

Other skills

  • Critical Thinking
  • Decision Making
  • Microsoft Office
  • Communication
  • Social Skills
  • Time Management
  • Problem Solving

About the company

ICONMA logo

ICONMA

Management Consulting

We provide Professional Staffing Services & Project-Based Solutions for a broad range of Fortune 500 organizations. ICONMA is a certified Woman-Owned staffing company and was founded in 2000. ICONMA’s corporate headquarters is in Troy, Michigan, and has 15+ locations worldwide. What makes ICONMA stand out in a fiercely competitive industry? *We provide integrated, full lifecycle services across a broad range of business and technical platforms. *No single company can duplicate our full range of staffing and permanent recruiting services nationwide. *Proven track record of attracting and retaining exceedingly skilled professional workers in a highly competitive market. SERVICES OFFERED Staff Augmentation (Contract, Contract to Hire, Direct Hire, Single Source) Data Analysis Project-Based Services & Solutions Hire Train Deploy Service Model Offshore Staff Augmentation Payroll Services AREAS OF EXPERTISE - Information Technology - Engineering - Business Professional - Accounting/Finance - Admin/Clerical/Call Center - Healthcare/Clinical/Scientific - Marketing/Creative mail linkedin@iconma.com Phone (888) 451-2519 Website http://www.iconma.com

Company details

Company typeLarge
IndustryManagement Consulting
Company size1001 - 5000

Links

Website LinkedIn See all jobs

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Job description

Our Client, a Medical Center company, is looking for a Prior Authorization Clinician for their Remote location.
 
Responsibilities:
  • Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination.
  • Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.
  • Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria
  • Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
  • Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.
  • Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
  • Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).
  • Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.
  • Sends appropriate system-generated letters to provider and member
  • Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
  • Follows all departmental policies and workflows in end-to-end management of cases.
  • Participates in team meetings, education, discussions, and related activities
  • Maintains compliance with Federal, State and accreditation organizations.
  • Identifies opportunities for improved communication or processes
  • May participate in audit activities and meetings
  • Documents rate negotiation accurately for proper claims adjudication
  • Identify and refer potential cases to Care Management
  • Performs all other related duties as assigned
 
Requirements:
  • Nursing degree or diploma required, bachelor’s degree in nursing
  • Preferred/Desirable:
  • Bachelor’s degree
  • RN license in state of MA, NH or compact license
  • Medicare and Medicaid knowledge
  • Experience:
  • 2+ years prior authorization experience and evidence-based guidelines (InterQual Guidelines)
  • Managed care experience
  • Licensure, Certification or Conditions of Employment:
  • Active, unrestricted RN license in state of residence
  • Pre-employment background check
  • Competencies, Skills, and Attributes:
  • Strong oral and. written communication skills.
  • Strong clinical judgement and critical thinking skills to assess complex cases and determine appropriate levels of care.
  • Excellent communication and interpersonal skills to engage effectively with internal and external stakeholders
  • Ability to work independently in a remote environment while maintaining adherence to timeliness and regulatory requirements.
  • Proficiency in Microsoft Office applications and data management systems.
  • Demonstrated organizational and time management skills
  • Strong analytical and clinical problem-solving abilities with focus on quality improvement initiatives
 
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MR

Marcus Rivera

Chief Revenue Officer

m.rivera@company.com
linkedin.com/in/marcusrivera
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