We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
Applies clinical knowledge to make determinations for pre-authorizations of specific procedures and services to ensure adherence to contract benefits. Conducts Medical / Surgical medical necessity reviews. Compiles information needed to process prior authorization requests and documents in the medical management information system. Prepares and presents more complex cases for Medical Director review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Education & Experience
Required:
- Licensed Practical Nurse or Licensed Vocational Nurse, with current unrestricted license in appropriate state or territory in the United States
- 2+ years’ experience with Medical / Surgical
- U.S. Citizenship – if assigned to TRICARE contract
- Must be able to receive a favorable interim and adjudicated final Department of Defense (DoD) background investigation – if assigned to TRICARE contract
- Proficient working with on-line systems
Preferred:
- 5 years’ experience with Medical / Surgical
- 1 year TriWest or TRICARE experience
- Managed Care experience
Key Responsibilities
- Conducts prior authorization activities and referral management activities.
- Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines, Clinical Decision Support Tool, and Behavioral Health criteria. Interprets information and makes decision whether authorizations fits the TriWest benefit program. Ensures timely reviews for requesting facilities and appropriate notification to parties.
- Contacts beneficiary and / or provider to obtain or clarify medical information as necessary.
- Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary.
- Prepares cases for Medical Director and Peer Review according to established policy.
- Refers potential quality issues and complaints to Clinical Quality Management.
- Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding.
Working Conditions
Working Conditions:
- Availability to work any shift
- Works within a standard office environment, with minimal travel
- Extensive computer work with prolonged sitting
