You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.

Job Summary

Our client is seeking a dedicated Prior Authorization Nurse to ensure timely completion of prior authorization requests in compliance with contractual and evidence-based standards. This role involves coordinating review processes for various services, evaluating patient medical records, making utilization decisions based on established guidelines, and communicating with medical professionals to facilitate comprehensive member care.

Responsibilities / Job Duties

• Ensures that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence based standards, with duties including but not limited to:
  • Coordinating and following the established preauthorization review process for outpatient and inpatient services
  • Functioning as a resource for LVN and non-licensed staff in evaluating reviews for members with complex conditions such as but not limited to transplants, gastric bypass, etc.
  • Reviewing both inpatient and outpatient authorization requests in an accurate, thorough and efficient manner;
  • Acute hospital pre-admission / Skilled Nursing Facilities / Hospice and other Long Term Care facilities
  • Surgical / Diagnostic procedures / Therapies / Durable Medical Equipment and Home Care
  • Making utilization decisions and recommendations based upon nationally recognized and evidence based guidelines adopted by our client such as Milliman Care Guidelines
  • Using Utilization Management (UM) software systems in an accurate and efficient manner
  • Producing volume of work to meet position requirements
  • Evaluating patient medical records when determining benefit coverage including appropriateness and level of care
  • Reviewing prior authorization requests with Medical Directors as directed
  • Preparing Notices of Action that meet contractual requirements
  • Assisting Member Services, Claims and Provider Services department staff with issues that require medical interpretation or definition
  • Communicating with physicians, ancillary providers and county service agencies to coordinate member care
  • Updating and processing member / provider information as directed

Minimum Education and Experience Qualification Requirements

Education

• Bachelor’s degree in Nursing.
• Current unrestricted license as a Registered Nurse issued by the State of California.

Qualifications

• Current working knowledge of Milliman Care Guidelines in review determination process.
• Knowledge of Utilization Management, and/or Case Management principles and practices.
• Some knowledge of Medi-Cal and related policy and Title 22 regulations.
• Some knowledge of utilization management principles and activities.
• Some knowledge of case management principles and activities.

Experience

• Minimum of three years of RN experience.
• Minimum of one year of experience in Utilization Management or Case Management in a plan setting.

Schedule / Shift

Monday - Friday 8am-5pm Pacific

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

Medix Overview:

With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.

Any required state or Joint Commission training is compensated at the state or local minimum wage rate.

^*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.