Prior Authorizations, Case Manager (LVN/RN)

Regal Medical Group•Los Angeles, CA

2d•$38 - $50

About The Position

The role of the Prior Authorization Review Nurse, LVN/RN is to promote the quality and cost effectiveness of medical care by applying clinical judgement and the appropriate application of policies and guidelines to prior authorization referral requests. The Prior Authorization Review Nurse, LVN/RN will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated. If not indicated, they will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed.

Requirements

Graduate from an Accredited Nursing Program
Active California Licensed Vocational Nurse license
Minimum of 1 year of processing prior authorization referrals experience
Knowledge of Healthcare and Managed Care
Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization
At least 1 year of clinical experience (SNF, Home health, Hospital, etc)
Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
Typing 45 WPM with accuracy
Ability to deal with responsibility with confidential matters
Ability to work in a multi-task, fast-paced, high-stress environment

Responsibilities

Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues.
Maintain a working relationship with Prior Authorization Case Management (PACM) colleagues, the prior-authorization coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network
Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies
Maintain regulatory Turnaround Time Standards per regulatory
Document accurately and completely all necessary information in authorization
Approve those approvable requests as indicated based on
Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation.
Understand all applicable capitation contracts and how they apply to review
For those PACMs involved in DME, understand the contracts, and need to review rental purchase approvals, and continued use so that equipment is picked up when needed.
When appropriate, coordinate and review for medical necessity and appropriate utilization for ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
Participates in “service recovery” through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
Identifies network needs and report to management for potential contracting
Excellent written and verbal communication skills to assist with writing job aids and training material for the staff.
Conduct trainings as needed.
Other duties as directed by management.