Prior Authorization Nurse

Medix is currently hiring a RN Prior Authorization Nurse for a Health Plan in Missouri. This position is a Monday - Friday (8a-5p) Central Time Zone. The candidate must have previous Prior Authorization experience from a Health Plan in order to be considered. See below for more details. This position is fully remote.

Job Overview

Utilizes a collaborative review process of benefits, minimally necessary clinical information and evidence-based clinical guidelines to formulate decisions regarding medical necessity, pre-existing conditions, benefits and/or individual consideration reimbursement allowables using varied and broad clinical expertise. Acts as a member and provider advocate promoting and coordinating delivery of quality, cost effective healthcare services based on medical necessity and contractual benefits

Responsibilities

• Conducts pre-service, concurrent and / or post-service utilization management reviews to ensure appropriate use of the health care system and to maximize health care dollars.
• Ensures that reviews and determinations meet requirements with applicable URAC and NCQA guidelines as well as federal and state mandates
• Reviews provider and/or member submitted medical information to determine pre-existing, medical necessity, benefits & eligibility, and/or reimbursement of a requested service, product or procedure utilizing professional knowledge, medical literature, medical records, certificate guidelines, medical policy, approved clinical guidelines
• Refers cases that do not meet criteria to the Medical Director with an appropriate clinical analysis, summaries and recommendations
• Contributes in the discharge planning of members to appropriate acute, SNF, in-patient hospice or rehab facilities or discharge to home with a safe plan

Qualifications

• RN license (compact)
• 3+ years full-time direct patient care clinical experience in medical/surgical, pediatrics, and/or obstetrics.
• 1+ year(s) of utilization review, disease management, and/or case management experience.
• Knowledge of URAC and NCQA guidelines and state and federal regulations