Prior Authorizations Nurse (RN)
C
Central California Alliance for HealthManaged care
Remote in CaliforniaTemporarySenior
Salary49 - 57.5 USD per hour
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Job Details
- Experience
- A minimum of five years of experience in a patient care setting, including a minimum of one year of experience in Utilization Management or Case Management.
- Required Skills
- Microsoft Excel
Requirements
- Hold a current unrestricted Registered Nurse license issued by the State of California.
- Have an associate degree in Nursing and at least five years of experience in a patient-care setting, including at least one year in Utilization Management or Case Management; a bachelor's degree may substitute for two years of the required experience.
- An equivalent combination of education and experience may qualify.
- Have working knowledge of managed care, Medicare D-SNP, Medi-Cal programs, and related regulations.
- Have working knowledge of Centers for Medicare & Medicaid Services (CMS) guidelines, including applicable Local Coverage Determinations and National Coverage Determinations.
- Have working knowledge of Microsoft Excel, PowerPoint, and database software.
- Know prior authorization principles and practices, clinical nursing principles and practices, MCG Guidelines, Medi-Cal regulations, and Title 22 regulations.
- Be able to evaluate medical records and other health care data.
- Be able to interpret, apply, and explain policies, regulations, terms, and procedures.
- Be able to maintain organized and accurate records.
Responsibilities
- Complete prior authorization requests in a manner that meets contractual requirements.
- Conduct prior authorization reviews using nationally recognized and evidence-based standards.
- Participate in Utilization Management (UM) Care Programs.
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