Licensed practical nurse health care

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.

When you join our team, you're making a great choice for your professional career and your personal satisfaction.

Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. The Authorization Nurse is responsible for the evaluation of medical appropriateness and necessity for a variety of services using contracts, medical policies, and evidence-based clinical guidelines while also ensuring benefit and eligibility requirements are met. They work with physician reviewers and providers to meet the health care needs of members so that they can receive efficient and timely medical care.

Review and process urgent and non-urgent authorization requests (received via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.

Process authorization requests (routine, urgent and retrospective) according to regulatory requirements.

Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions. Criteria may include MCG, Hill Guidelines, Health Plan Criteria, Health Plan and Hill Physician contracted provider data and member benefit information.

Obtain additional medical information as necessary from requesting provider.

Case Management, Health Education, TPL, COB).

Ensure quality authorization processing while meeting individual and team productivity standards.

Clearly and succinctly document necessary and/or required information in Epic Tapestry system.

Prepare and present cases to physician reviewers/UM Medical Director in a concise, objective and organized manner.

Collaborate with physician reviewers, Utilization Management Medical Director and other designated physician leaders on making clinical decisions.

Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.

Registered (RN) or Licensed Vocational Nurse (LVN).

Bachelor's degree in nursing strongly preferred

Minimum 3 or more years pertinent experience in Managed Care Utilization Management

Experience with medical decision supports tools such as MCG.

Previous experience with Epic Tapestry platform preferred but not required.

Knowledge of ICD-10 and CPT coding.

Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)

Ability to work effectively with a variety of customers including physicians, office staff, and members.

Adaptable/flexible -- enjoys doing work that requires frequent shifts in direction

Hill Physicians is an Equal Opportunity Employer

Hill Physicians Medical Group