Job Description PURPOSE: The Prior Authorization Nurse will document and process prior-authorizations for HMO Medi-Cal, Medicare, Medi-Medi and Commercial patients based on established policies, procedures, Reference Manuals, Rosters, Health Plan Contracts and DOFR.
Clinical guidelines used include Medi-Cal, CMS, Health Plan, Apollo and Milliman Care guidelines.
ESSENTIAL DUTIES: Reviewing each referral authorization request, comparing against patient’s authorization request history and applying criteria in determining approval or denial decision.
Creating deferral letters to obtain medical records or additional information Timely processing of prior authorization referrals from primary care physicians and specialists Documentation of denial recommendations with clinical criteria for Medical Director review Average daily referral volume of 75 referrals MINIMUM REQUIREMENTS 2-5 years of experience in a Managed Care setting Knowledge of California’s federally funded healthcare programs: Medi-Cal, Medicare, Medi-Medi, CalMediConnect and Covered California.
Organized, efficient and possess superior attention to detail Punctual, prepared and able to meet or beat deadlines Excellent written and verbal communication skills Knowledge or experience in prior authorizations in the managed care setting EDUCATION/TRAINING Valid California Nursing License in good standing with no restrictions High School diploma College degree preferred On Site training will be provided LANGUAGE SKILLS Ability to communicate and speak effectively before co-workers, management, and external contacts Ability to fluently speak, write, and understand English Ability to write routine emails and other correspondence Ability to speak clearly and concisely over the telephone CONFIDENTIAL AND SENSITIVE INFORMATION: Must properly control the release of proprietary and confidential information Note that the information above is intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified.
Furthermore, they do not establish a contract for employment and are subject to change at the discretion of the employer.
Company Description Electronic Health Plans works collaboratively with Preferred IPA of California, providing the best possible care management, care coordination, and claims processing services to Preferred IPA and their members.
We work with the network’s participating physicians to coordinate patient care when a referral is made to a specialist or hospital for diagnosis and treatment.
We coordinate patient care across all aspects of the provider network.
In this way, the Electronic Health Plans team makes its best efforts to provide high quality services to its participating physicians and superior health care to its members.