Job Description

POSITION SUMMARY

Reports to the UM Manager. This position is a position for a California Licensed Nurse whose primary responsibilities are to perform the prospective and retrospective review of the requests for service authorizations in order to monitor the continuity and coordination of care and to assist in the utilization of appropriate services. The Prior authorization Nurse conducts these reviews of authorization requests to verify accurate provider specialties, medical treatments and services, place of service and or facilities. Also oversees the Prior Authorization Coordinators to direct appropriate utilization and data.

RESPONSIBILITIES & DUTIES:

• Determines compliance of pre-established medical necessity criteria applying Milliman, and Healthcare Management Guidelines.
• Redirects members for alternative treatment/service that are appropriate to the members condition after they have been reviewed with the UM Manager or Medical Director.
• Will identify cases requiring potential or actual use of medically in appropriate interventions and refers these to the UM Director & Medical Director for review.
• Should be able to process a minimum of 100-150 auths per day.
• Will interact with providers for medical information necessary to adjudicate authorizations.
• Will review authorizations and see if it’s clinical history supports service/procedure that’s being requested.
• Will review requested authorizations and verify it is requested to appropriate provider and service area.
• Will review potential denial of service with the UM Director & Medical Director.
• Must investigate and follow up on all requests for additional information by UM Manager and/or Medical Director.
• Will be the primary resource for the Prior Authorization Coordinators.
• Will educate providers as needed with the Authorization/Referral process.
• Will be primary point of contact with the providers on urgent authorization requests.
• Must identify and report to the QM Department of any potential quality of care issues and /or pre-established UM referral indicators.
• Must maintain confidentiality on all member medical/clinical information.
• Will perform other job duties as necessary to accommodate departmental change, workload and/or emergencies.
• Must ensure the privacy and security of PHI(Protected Health Information) as outlined in policies & procedures relating to HIPPA compliance.
• Must have understanding of all Medical Management policy and procedures, and NCQA guidelines.

JOB REQUIREMENTS

• Language and communication skills, must be able to communicate both orally and in writing, have the ability to read and comprehend simple instructions.
• Mathematical skills have the ability to add, subtract, multiply and divide in all units of measure using whole numbers, common fractions & decimals. Have the ability to compute rate, ratio, percent and to draw and interpret bar graphs.
• Decision making be able to recognize and properly handle confidential health information. Be able to efficiently prioritize multiple high priority tasks. Define problems and collect data, establish the facts, and draw a valid conclusion. Interpret an extensive variety of technical instructions in mathematical form.
• Computer skills: have knowledge of the Internet, MS Word and Excel. Knowledge of office machinery (phones, fax machines, etc). And the willingness and capacity to learn new software tools when necessary.
• Must have graduated from an accredited Nursing program.
• Must have current CA LVN license.
• One to two years related experience of education and experience.
• Experience using MCG Criteria.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On : Full employer-paid HMO and the option for a flexible PPO plan .
• Wellness Made Affordable : Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending : FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance : Generous PTO , 40 hours of sick pay , and 13 paid holidays to enjoy life outside of work.
• Career Development : Tuition reimbursement to support your education and growth.
• Team Fun : Paid company outings and lunches because we work hard, but we also know how to have fun!

Join AMM and experience a workplace where your health, growth, and happiness comes first!

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