Prior Authorization/Utilization Management Nurse - with Growth Opportunities

We are hiring a motivated Prior Authorization/Utilization Management Nurse to join our exceptional team at Provider Partners Health Plan in null
Growing your career as a Full Time Prior Authorization/Utilization Management Nurse is an incredible opportunity to develop useful skills.
If you are strong in creativity, cooperation and have the right initiative for the job, then apply for the position of Prior Authorization/Utilization Management Nurse at Provider Partners Health Plan today!

Prior Authorization/Utilization Management Nurse plays a critical role in facilitating access to appropriate healthcare services while ensuring cost-effective utilization of resources and adherence to quality and regulatory standards. Responsibilities: Evaluate requests for medical services, procedures, medications, or durable medical equipment (DME) to ensure they meet the necessary criteria for coverage under the member's insurance plan. Asses the medical necessity of the requested services or treatments based on established clinical guidelines, evidence-based medicine, and insurance policies. Communicate with healthcare providers, including physicians, specialists, and other healthcare professionals, to gather additional information, clarify clinical details, or discuss alternative treatment options when necessary. May perform utilization review to evaluate the appropriateness, efficiency, and quality of healthcare services provided to members, ensuring that resources are used effectively and in accordance with established standards. Must maintain accurate and detailed records of prior authorization requests, decisions, and communications with healthcare providers and members. Ensure compliance with relevant laws, regulations, and industry standards governing healthcare practices, member privacy, and insurance coverage. Collaborate with other departments within the organization, such as claims, customer service, and medical management, to facilitate the timely processing of prior authorization requests and address any issues or concerns. Provide education and support to members regarding their insurance coverage, prior authorization process, and available resources for accessing healthcare services. Participate in quality improvement initiatives aimed at enhancing the efficiency, accuracy, and effectiveness of the prior authorization process and overall healthcare delivery. Participate as member of the Special Investigation Unit (SIU) Committee Ad Hoc claims and medical records review Review claim submissions (post or pre paid) and medical records as necessary for Fraud, Waste and Abuse investigations Prepare recommendations to either uphold or deny based on review. Requirements Registered Nurse (RN) license in good standing. Bachelor's degree in nursing (BSN) preferred. Prior experience in prior authorization, utilization management, or case management within a healthcare setting. Strong clinical assessment and critical thinking skills. Excellent communication and interpersonal abilities. Proficiency in navigating electronic health records (EHR) and insurance verification systems. Ability to work independently and collaboratively in a fast-paced environment. Attention to detail and accuracy in documentation and data entry. Commitment to maintaining member confidentiality and privacy. Willingness to adapt to changing priorities and evolving healthcare regulations. #J-18808-Ljbffr

Benefits of working as a Prior Authorization/Utilization Management Nurse in null:

● Excellent benefits
● Advancement opportunities
● Attractive package