Prior Authorization Nurse
New
State of ArizonaFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 3 years of clinical experience, 1 year of Medicaid/Medicare experience, 1 year prior authorization and member and provider notification (NOA) experience, 1 year experience with National Committee for Quality Assurance (NCQA) standards
- Required Skills
- Microsoft ExcelMicrosoft Office
Requirements
- 3 years of clinical experience
- 1 year of Medicaid/Medicare experience
- 1 year prior authorization and member and provider notification (NOA) experience
- 1 year experience with National Committee for Quality Assurance (NCQA) standards
- Associate degree in Nursing
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN or LPN
- Computer skills to include Microsoft Office applications, Word, Excel, and Outlook
- Ability to use electronic medical management systems
- Analytical problem solving skills
Responsibilities
- Ensures the accuracy and timeliness of prior authorization requests to meet contractual requirements.
- Coordinates and manages the established preauthorization review process for pre-service requests.
- Ensures the use of nationally recognized and evidence-based standards in the completion of all pre-service reviews.
- Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request(s) to the medical director for determination when criteria not met.
- Clearly define and document review rationale to support approval, Medical Director Review and/or Notice of Action document.
- Initiates interdepartmental coordination to ensure quality and timely care for members.
- Participates in Quality Improvement Projects as directed.
- Participate in department audits and other regulatory activities.
- Engage cross-functionally and participate in special projects as needed.
- Performs Notice of Action (NOA) process.
- Participate in annual policy and procedure review and revision.
- Perform all other duties as assigned.
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