Registered Nurse RN (Precertification/Prior-Authorization)

Registered Nurse RN (Precertification/Prior-Authorization)

Looking for a RN with Prior Authorization or Pre-Certification not case management experience. Clinical experience on a medical surgical unit/surgical area or home care experience.

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management.

Responsibilities include assessing patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates and assists in implementation of plan for members. Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. Encourages member participation and compliance in the case/disease management program efforts. Documents accurately and comprehensively based on the standards of practice and current organization policies. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Completes other assigned functions as requested by management.

Core individual contributor competencies include customer focus, accountability, learning, and communication.

Knowledge includes proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; knowledge in the use of intranet and internet applications. Working knowledge of case/care management principles, principles of utilization management, health care contracts and benefit eligibility requirements, and hospital structures and payment systems.

Skills and abilities include analytical, compassion, interpersonal & client relationship skills, judgment, listening, planning/priority setting, problem solving, team player, time management, and written/oral communication & organizational skills.

Education/experience includes an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. Requires a minimum of two (2) years clinical experience. Requires an active New Jersey Registered Nurse License.