Pre-Authorization Nurse

Pre-Authorization Nurse

The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Pre-Authorization Nurse 2 will assist TRICARE beneficiaries in receiving the highest quality specialty healthcare through management of the referral/authorization process. Support front line telephone agents in dealing with beneficiaries and providers. Identify and direct beneficiaries to the most appropriate, cost-effective medical care. Have an understanding of TRICARE policy and HM policies and procedures related to the processing of referrals and authorizations. Be able to apply this information in assisting beneficiaries, providers, and phone agents.

The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment and refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.