Nurse Case Manager, Prior Authorization RN

Nurse Case Manager, Prior Authorization RN

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources. HCP's vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP's mission of serving our members by facilitating the delivery of quality care. Interested in joining our successful Garden City Team?

We are currently seeking a Nurse Case Manager, Prior Authorization RN! Position Summary: The Nurse Case Manager, Prior Authorization RN is responsible for reviewing and processing prior authorization requests for medical services, ensuring that all clinical criteria and health plan requirements are met. This role reports to the Manager of Inpatient Utilization Management and involves collaborating with healthcare providers, patients, and internal teams to determine the medical necessity of requested services, ensuring compliance with insurance guidelines, and maintaining accurate documentation. The Nurse Case Manager, Prior Authorization RN will support the goal of delivering timely and efficient authorization decisions while promoting quality patient care.

Essential Position Functions/Responsibilities:

• Review incoming prior authorization requests for medical services, including procedures, medications, and diagnostic tests, ensuring that they meet clinical guidelines and health plan requirements.
• Evaluate medical records, clinical documentation, and provider notes to determine the medical necessity and appropriateness of requested services based on established criteria.
• Communicate with healthcare providers, including physicians and specialists, to obtain additional information or clarification needed to process prior authorization requests.
• Work closely with other teams, such as utilization management, care management, and pharmacy, to ensure accurate and timely processing of prior authorization requests.
• Ensure all prior authorization processes comply with relevant healthcare regulations, health plan policies, and turnaround time standards.
• Accurately document the review process, decisions, rationale, and outcomes of prior authorization requests, maintaining clear and comprehensive records in the system.
• Support the review and resolution of denied prior authorization requests, including assisting with the preparation of information for appeals, when necessary.
• Educate healthcare providers and patients on the prior authorization process, required documentation, and health plan requirements.
• Assist in identifying opportunities for process improvements in the prior authorization workflow to increase efficiency and reduce errors.
• Ensure that prior authorization requests are processed within designated time frames to meet regulatory and health plan requirements.

Qualification Requirements: Skills/Knowledge/Abilities

• Strong understanding of clinical procedures, diagnoses, and treatments, with the ability to assess medical necessity based on evidence-based guidelines (MCG, National Coverage Determinations and Local Coverage Determinations).
• Excellent written and verbal communication skills, particularly in interacting with healthcare providers and patients in a professional and clear manner.
• Ability to manage multiple requests simultaneously while maintaining a high level of accuracy and efficiency.
• Strong critical thinking and decision-making skills to evaluate requests and address issues related to medical necessity and health plan compliance.
• Understanding of the prior authorization process, including guidelines, clinical review criteria, regulatory requirements and turnaround time expectations.
• Ability to adapt to changing health plan requirements, clinical criteria, and workflow processes.

Training/Education:

• Registered Nurse (RN) with an active and unrestricted nursing license in the state of practice required; Bachelor's degree in Nursing (preferred).

Experience:

• At least 2-3 years of clinical nursing experience, with at least 1 year in utilization management, prior authorization, or a related healthcare setting.
• Experience in reviewing medical records, clinical documentation, and prior authorization requests.
• Familiarity with clinical decision-making criteria and evidence-based guidelines used in the prior authorization process (preferred).

Base Compensation: $90,000 – 105,000 annually Bonus Incentive: Eligibility based off organizational performance Benefits: Fully paid Medical & Dental employee coverage + robust benefits package (PTO, 401k, FSA, Tuition Reimbursement, etc.) Equal Employment Opportunity Statement: HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non-discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Job Disclaimer: The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.