General Summary
Prior Authorization/Nurse Job Description
The Prior Authorization/Care Management Nurse (medications/treatments) will contact insurance companies, on behalf of Littleton Regional Healthcare Physician Practices, to verify patient specific benefits and authorizations/referrals for medications and treatments as required by the insurance carrier. This nurse will ask appropriate questions regarding patient’s benefits and complete data entry and/or appropriate forms to document patient’s benefits coverage. This nurse may be asked to work denials on the authorizations that had been obtained. This nurse will work to coordinate care for medication management with outpatient/inpatient infusion centers. This nurse will work to coordinate care with home health agencies in assisting with medication and care management of patients within our communities.
Essential Functions
- Work closely with the Nurse Supervisor to ensure that all medication and treatment authorizations are documented completely and submitted in a timely manner
- Communicate authorization denials to ordering physicians
- Prioritize and organize all prior authorization activities
- Serve as a liaison between patient, insurer, and practice
- Work on denials
- Prepare written communication to notify appropriate staff of authorization updates and or changes for insurance carrier
- Schedule peer-to-peer discussions if medications/treatments prior authorizations are denied.
- Keep track of pending authorization until decision is made.
- Contact insurance companies to obtain prior authorization via telephone and/or portals and provides necessary clinical documentation to ensure authorization is obtained prior to the scheduled treatment and/or retroactively as needed
- Ability to multitask between computer and multi-line phone requests
- Communicates plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team. Facilitates communication between the physician, interdisciplinary team, patient and family
- Gathers sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost effective manner.
- Organizes, integrates and evaluates the effectiveness of the plan of care and progress toward achievement of desired outcomes.
- Coordinates patient transfer to the appropriate level of care. Identifies and facilitates resolution of clinical and operational roadblocks to achieve optimal outcomes by identifying alternatives as needed.
- Documents all care management assessments and interventions.
- Rounds regularly with physicians to establish a plan of care, and to ensure that care is proceeding in an efficient and effective manner. Follow up to ensure that tests and treatments are proceeding efficiently, and that results are available to physicians on a timely basis.
- Works with outpatient infusion facilities and home health to coordinate care between the outpatient clinics and those ancillary services
- Perform other duties as assigned by nurse supervisor
Minimum Knowledge, Skills, And Abilities
- Bachelor’s or Associate Degree in Nursing (Bachelor’s preferred)
- State licensure as a Registered Nurse (RN)
- Minimum of two (2) years of experience in acute clinical nursing setting
- Knowledge of utilization management and case management principles preferred
- One to two years of experience with prior authorization process preferred
- Cerner experience preferred.
- Ability to deal tactfully and effectively with patients, family members, staff member, and physicians
- Excellent customer service and communication skills
- Ability to represent the organization and serve consumers in a professional manner and promote a positive image of the organization and its services.
- Excellent interpersonal skills required.
- Critical thinking skills a must.
- Detail oriented with the ability to multitask.
- Assist with patient inquiries.
Physical Demands
See Physical Demands worksheet
Work Environment
Exposure to communicable diseases, toxic substances, bodily fluids, medicinal preparations and other conditions common to a clinic environment.
