The Prior Authorization Nurse manages specialty referral requests by applying clinical guidelines to ensure appropriate care and cost-effectiveness. They act as a liaison between providers, health plans, and patients while maintaining accurate documentation and regulatory compliance.
Requirements summary
Candidates must hold an active California LVN or RN license and have at least one year of experience in processing referrals and authorizations. Proficiency in MS Office and knowledge of managed care and regulatory requirements like NCQA and CMS are required.
The role of the Case Manager, Prior Authorization Nurse is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests. The Case Manager, Prior Authorization LVN will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated. If not indicated, they will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed.
Essential Duties and Responsibilities include the following
Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues.
Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high- risk nurse case managers, inpatient nurse case managers, medical directors, and network
Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies
Maintain regulatory Turnaround Time Standards per regulatory
Document accurately and completely all necessary information in authorization
Approve those approvable requests as indicated based on
Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation.
Understand all applicable capitation contracts and how they apply to review
For those PACMs involved in DME, understand the contracts, and need to review rental purchase approvals, and continued use so that equipment is picked up when needed.
When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
Participates in “service recovery” through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
Identifies network needs and report to management for potential contracting
Excellent written and verbal communication skills to assist with writing job aids and training material for the staff.
Conduct trainings as needed.
Other duties as directed by management.
The pay range for this position at commencement of employment is expected to be between for LVN's $37.50 - $40 for RN's $45 - $50 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
Qualifications
Education and / or Experience
Graduate from an Accredited Nursing Program
Active California Licensed Vocational Nurse & Registered Nurse license
Minimum of 1 year of processing referrals and authorizations experience
Knowledge of Healthcare and Managed Care
Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization
Knowledgeable with the pre authorization process and workflow, with prior authorization experience preferred
Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
Typing 30 WPM with accuracy
Ability to deal with responsibility with confidential matters
Ability to work in a multi-task, fast-paced, high-stress environment
