Prior Auth Nurses - San Diego Network

Job description

Position Summary: The role of the 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 Prior Authorization Nurse 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 nurs...