Job Profile Summary
Position Purpose:
Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required
For Superior Health Plan: RN license required
Responsibilities
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
Provides feedback on opportunities to improve the authorization review process for members
Performs other duties as assigned
Complies with all policies and standards
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Story Behind the Need
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
Review Prior Authorization requests for various service types for the Medicaid LOB
Recent layoffs and voluntary separations have caused a gap in FTEs vs the inventory
Team is collaborative and supportive; Team is REMOTE but team relies heavily on communication
This initiative is multi state/region but there are only 3 under me
Typical Day in the Role
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
Team member will receive an assignment that is LIVE (excel spreadsheet)
Team member will process various authorization service types using clinical coverage policies or InterQual.
Team member will submit any requests that do not meet criteria to second level review (MD) for a determination.
12-15 nurse reviews per day
NA
Candidate Requirements
Education/Certification
Required: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
Preferred:
Licensure
Required: LPN COMPACT
Preferred: RN Compact
Years of experience required: 3+ related experience
Disqualifiers:
Additional qualities to look for: Organized team player who is willing to learn in a fast pace environment
- Top 3 must-have hard skills stack-ranked by importance
1
Computer literacy
2
Prior experience with prior authorization
3
Prior experience using state clinical coverage policies (Medicaid)
Candidate Review & Selection
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
Projected Manager Candidate Review Date:
1-2 days post shortlisting
Type of Interviews:
TEAMS – camera on
Required Testing or Assessment (by Vendor):
NA
Next Steps
- Do you have any upcoming PTO?
Oct 8 th – 13 th
- Colleagues to cc/delegate
Katherine Grizzard
