Prior Authorization Nurse

Job description

The Prior Authorization Review Nurse is responsible for supporting the process that manages all outpatient services. The goal of the Prior Authorization Review Nurse is to actively participate in the review of, current services being rendered and requests for service, and to follow guidelines in the approval of those services or making recommendations for other determinations to the provider reviewer in the most cost effective manner, and ensures the optimum quality of care is provided. Essential Duties and Responsibilities include the following: - Plan, research alternative and assist in the routing of member to the most appropriate IPA provider (s), ancillary providers and sites of care. - Act as liaison between the case managers, UM coordinators, contracted providers, and the members. patients, providers, and other healthcare providers. - 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 community standards and health plan/ CMS guidelines. - Collaborate and communicate with all the members of hea...