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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Skills:
Analysis Skills, Business Growth, Clinical Information, Clinical Nursing, Clinical Validation, Contract Requirements, Cost Effectiveness Analysis, Cross-Functional, Discharge Plans, Diversity, Health Information Management, Health Plan, Healthcare Providers, Healthcare Software, Maintain Compliance, Medicaid, Medicare, Nursing, Nursing Credentials, Patient Care, Patient Care Authorizations, Performance Metrics, Process Improvement, Quality Management, Quality of Care, Registered Nurse (RN), Regulations, Regulatory Compliance, Strategic Planning, Team Player, Time Management, Training/Teaching, Utilization Management

Mindlance