Authorization Nurse, RN - 26-66

Overview We’re delighted you’re considering joining us! At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members. Job Description: Evaluate authorization requests and authorize, modify or pend per appropriate criteria. Refer authorization requests not meeting criteria to specialty physician reviewer according to established medical necessity, benefit and eligibility criteria to assure appropriate, efficient and timely medical care. Responsibilities Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate. Obtain additional medical information as necessary from requesting provider. Communicate with providers and members regarding status of authorization requests. Collaborate with Medical Directors and other designated physician leaders for making clinical decisions. Assist interdepartmental staff members to resolve issues relating to the authorization process. Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB). Process authorization requests (routine, urgent and retrospective) according to department performance standards. Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned. Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements. Perform other duties as assigned by supervisor/manager. Qualifications Experience: Minimum three years clinical nursing experience. Utilization Management experience preferred. Excellent verbal and written communication skills. Ability to work effectively with a variety of customers including physicians, office staff, and members. Ability to work independently with self-initiative and discipline. Working knowledge of personal computers. Managed care experience and certification preferred. Knowledge of ICD-10 and CPT coding. Optimum organizational skills with ability to meet expected and unexpected time frames. Education: Active, unrestricted California Licensure: Registered (RN) or Licensed Vocational Nurse (LVN). Additional Information Annual Salary Range: $110,000 to $123,350. Hill Physicians is an Equal Opportunity Employer. PriMed Management Consulting Services, Inc., is the management services organization for Hill Physicians Medical Group. #J-18808-Ljbffr PriMed Management Consulting Services, Inc.