Position Title:            UM Prior Authorization (PA) Nurse         

Department:              Care Management (UM)                   

Reports To:                Outpatient UM Supervisor             

Classification:            Non-Exempt     

Status:                        Full-Time Regular

POSITION SUMMARY

The purpose of the Prior Authorization Nurse is to provide patients, physicians and CHCN partner clinics with strong clinical support related to the review and approval of medical service authorization requests. The position supports CHCN goals to ensure the appropriate utilization of the organizations’ resources.  This position will identify, screen, coordinate and process authorization requests covering the entire spectrum of medical services. The Nurse will use best clinical judgment to make determinations of coverage and medical necessity for requested services. This position supports CHCN’s Medical Directors with case review prep including medical review criteria for PA determinations that require M.D. intervention. The PA Nurse interacts with other UM team members to support departmental efforts and goals.

ESSENTIAL POSITION RESULTS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks and responsibilities. Employees may perform other duties as assigned.

• Responsible for providing timely referral determination by accurate application of medical review criteria including, MCG (Milliman Care Guidelines).
• Appropriate and timely identification of referral requests requiring Medical Director review.
• Appropriate member and provider “Notice of Action” language selection for all UM determinations.
• Appropriate selection of preferred and contracted providers, when possible, within CHCN’s network.
• Proper identification of member eligibility and health plan benefits.
• Responsible for maintaining turn-around-time requirements (TAT) according to ICE standards.
• Responsible for working closely with supervisor/lead to address issues and delays that impact TAT compliance.
• Continuous monitoring of pended documents for final determination.
• Responsible for working directly with Medical Director’s to review and properly address such cases as possible CCS, high dollar requests, and health plan overturns.
• Responsible for attending internal and external meetings and trainings as requested. Work directly with the Health Plans, Providers, CCS, and Medical Directors to facilitate the delivery of quality care and services to members and CHCN clinics.
• Responsible for maintaining job performance standards as defined by CHCN.
• Responsible for improved customer service and telephone communications with all callers, both internal and external.
• Attend all mandatory customer service and ethics training.
• Maintain and keep in total confidence, all files, documents and records that pertain to the operation of business.
• All other job related duties as it relates to the job function or as delegated by the management team.

SUPERVISORY RESPONSIBILITIES

 None