Job Description:

The Authorization Nurse is responsible for the evaluation of medical appropriateness and necessity for a variety of services using contracts, medical policies, and evidence-based clinical guidelines while also ensuring benefit and eligibility requirements are met.  They work with physician reviewers and providers to meet the health care needs of members so that they can receive efficient and timely medical care.

Job Responsibilities:

• Review and process urgent and non-urgent authorization requests (received via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.

• Process authorization requests (routine, urgent and retrospective) according to regulatory requirements.

• Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions. Criteria may include MCG, Hill Guidelines, Health Plan Criteria, Health Plan and Hill Physician contracted provider data and member benefit information. 

• Obtain additional medical information as necessary from requesting provider.

• Communicate with providers and members regarding status of authorization requests.

• Assist interdepartmental staff members to resolve issues relating to the authorization process.

• Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).

• Ensure quality authorization processing while meeting individual and team productivity standards.

• Clearly and succinctly document necessary and/or required information in Epic Tapestry system.

• Utilize critical thinking skills to identify process issues and problems and recommend and/or implement solutions.

• Prepare and present cases to physician reviewers/UM Medical Director in a concise, objective and organized manner.

• Collaborate with physician reviewers, Utilization Management Medical Director and other designated physician leaders on making clinical decisions.

• Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.

• Perform other duties as assigned by supervisor/manager.

.

Skills and Experience Required:

• Active, unrestricted California Licensure: Registered (RN) or Licensed Vocational Nurse (LVN).

• Bachelor’s degree in nursing strongly preferred

• Minimum 3 or more years pertinent experience in Managed Care Utilization Management

• Experience with medical decision supports tools such as MCG.

• Previous experience with Epic Tapestry platform preferred but not required.

• Knowledge of ICD-10 and CPT coding.

• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)

• Excellent verbal and written communication skills.

• Ability to work effectively with a variety of customers including physicians, office staff, and members.

• Demonstrated organization and time management skills with the ability to prioritize workload and meet expected and unexpected time frames.

• Strong analytical and critical thinking skills.

• Ability to take action in solving problems exhibiting sound judgement.

• Demonstrated comfort with ambiguity and change.

• Ability to work independently with self-initiative and discipline.

• Adaptable/flexible -- enjoys doing work that requires frequent shifts in direction

• Detail-oriented -- would rather focus on the details of work than the bigger picture

• High stress tolerance -- thrives in a high-pressure environment

• Demonstrated critical thinking and inquisitiveness in reviewing UM cases for appropriate global review and decision-making.

Additional Information:

Salary: $100,000 - $123,000 Annual