Job Description

The role of the Case Manager, Prior Authorization RN is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests. The Case Manager, Prior Authorization RN will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated. If not indicated, they will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed.

Essential Duties and Responsibilities include the following:

• Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
• Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues.
• Maintain a working relationship with PACM colleagues, the pre-authorization coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management.
• Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
• When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
• Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies.
• Maintain regulatory Turnaround Time Standards per regulatory guidelines.
• Document accurately and completely all necessary information in authorization notes.
• Approve those approvable requests as indicated based on protocols.
• Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation.
• Understand all applicable capitation contracts and how they apply to review duties.
• For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed.
• When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
• Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
• Participates in “service recovery” through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
• Identifies network needs and report to management for potential contracting opportunities.
• All other duties as directed by management.

Organizational Responsibilities

• Proactively support and practice company mission, vision and values.
• Follow Employee Handbook guidelines and company policies and procedures.
• Follow established departmental dress code.
• Appropriately and accurately maintain time keeping records.
• Adhere to attendance policy and time off requests.
• Follow safety policies and procedures.
• Be flexible and adaptable and courteous and promote professionalism.
• Communicate verbally and in writing through appropriate channels.
• Maintain confidentiality at all times in compliance with company policy and HIPAA requirements.
• Employee has completed all required annual Compliance training and signed attestation form is attached for each module.

The pay range for this position at commencement of employment is expected to be between $37.50-$40/hour for LVNs and $45-$50/hour for RNs ; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

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If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

Qualifications

Education and/or Experience:

• Graduate from an Accredited Nursing Program
• Active California Registered Nurse license
• Minimum of 1 year of processing referrals and authorizations experience
• Knowledge of Healthcare and Managed Care preferred
• Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management
• Knowledgeable with the pre authorization process and workflow, with prior authorization experience preferred
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Typing 30 WPM with accuracy
• Ability to deal with responsibility with confidential matters
• Ability to work in a multi-task, fast-paced, high-stress environment