Prior Authorization Nurse

The Authorization Nurse will evaluate authorization requests and authorize, modify or pend per appropriate criteria. They will also refer authorization requests not meeting criteria to specialty physician reviewer according to established medical necessity, benefit and eligibility criteria to assure appropriate, efficient and timely medical care.

Job Responsibilities

• Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate
• Obtain additional medical information as necessary from requesting provider.
• Communicate with providers and members regarding status of authorization requests
• Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.

Additional Responsibilities

• Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.
• Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions. Criteria may include MCG, Hill Guidelines, Health Plan Criteria, Health Plan and Hill Physician contracted provider data and member benefit information.
• Obtain additional medical information as necessary from requesting provider.
• Communicate with providers and members regarding status of authorization requests.
• Assist interdepartmental staff members to resolve issues relating to the authorization process.
• Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).
• Process authorization requests (routine, urgent and retrospective) according to department performance standards.
• Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.
• Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.
• Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.
• Perform other duties as assigned by supervisor/manager.
• Assist interdepartmental staff members to resolve issues relating to the authorization process.
• Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).
• Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.
• Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.