About the position

The Pre-Authorization Nurse 2 plays a crucial role in the healthcare system by reviewing prior authorization requests to ensure that patients receive appropriate care and services. This position requires a thorough understanding of clinical guidelines and policies, as the nurse must determine whether to approve services or escalate requests to the appropriate stakeholders. The role involves completing medical necessity and level of care reviews for requested services, utilizing clinical judgment to assess each case's unique circumstances. The nurse will also educate healthcare providers on utilization and medical management processes, ensuring that all parties are informed and compliant with established protocols. In addition to reviewing requests, the Pre-Authorization Nurse 2 is responsible for entering and maintaining pertinent clinical information in various medical management systems. This requires a keen attention to detail and the ability to navigate multiple software platforms effectively. The nurse must understand the department's, segment's, and organizational strategies and objectives, recognizing how these link to related areas within the healthcare system. The role often involves making independent decisions regarding work methods, particularly in ambiguous situations, and the nurse will receive minimal direction while being guided as needed. Following established guidelines and procedures is essential to ensure compliance and quality of care. This position is not only about clinical assessments but also about making a positive impact on patient care by ensuring that the right services are provided at the right time. The Pre-Authorization Nurse 2 must be passionate about contributing to an organization that prioritizes improving consumer experiences and health outcomes.

Responsibilities

• Review prior authorization requests for appropriate care and setting.
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• Approve services or forward requests to the appropriate stakeholder.
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• Complete medical necessity and level of care reviews using clinical judgment.
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• Educate providers on utilization and medical management processes.
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• Enter and maintain pertinent clinical information in various medical management systems.
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• Understand department, segment, and organizational strategy and operating objectives.
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• Make independent decisions regarding work methods in ambiguous situations.
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• Follow established guidelines and procedures.

Requirements

• Active RN license in the state(s) in which the nurse is required to practice.
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• Ability to be licensed in multiple states without restrictions.
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• A minimum of three years varied nursing experience.
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• Less than 5 years of technical experience.
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• Proficient with MS Office products including Word, Excel, and Outlook.
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• Ability to work independently under general instructions and with a team.
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• Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Nice-to-haves

• Previous Medicare/Medicaid experience.
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• Previous experience in utilization management, case management, discharge planning and/or home health or rehab.
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• Health Plan experience working with large carriers.
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• Experience working with MCG or Interqual guidelines.

Benefits

• Health benefits effective day 1
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• Paid time off, holidays, volunteer time and jury duty pay
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• Recognition pay
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• 401(k) retirement savings plan with employer match
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• Tuition assistance
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• Scholarships for eligible dependents
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• Parental and caregiver leave
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• Employee charity matching program
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• Network Resource Groups (NRGs)
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• Career development opportunities