Prior Authorization Nurse

Job description

·  Job Description:

The Insurance/Healthcare job family contains positions associated with providing consultancy utilizing knowledge and expertise on insurance and healthcare. Develops and implements general insurance and health policies in accordance with state and federal laws. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions. Responds to provider appeals and meets with providers to resolve problems/issues. Provides directions for utilization review. Approves any remedial or recoupment actions associated with escalated claims. Advises provider review councils, state officials and works with organized healthcare groups and associations on various medical issues related to insurance and healthcare programs

Responsibilities:

Under minimal direction, provide clinical expertise to staff, management and customer within a health care account. Act as liaison to customers, providers, and recipients by resolving problems and clarifying medical and healthcare issues. Recommend and promote beneficial changes to customer programs to promote access to quality care and control of benefit packages. Assist in adjudication of medically complicated claims. Participate in customer’s policy development. Provide assistance in drafting provider manuals, bulletins, and revisions to promote publication. Assist with organized healthcare groups and associations on various medical issues related to the State’s medical program. This clinician will be part of the Prior Authorization team. The team has the responsibility for the following: to review, assess, and pre-approve selected non-emergency medical services prior to the actual delivery. The clinician is to help with cost containment and utilization review measures to make payment for only those treatments and services that are medically necessary, appropriate, and cost effective. The clinician provides support to the case management functions by accepting treatment plans as a form of prior authorization. Other duties may be assigned as required.

Position Prerequisites:

·  Bachelor’s degree or equivalent work experience or combination of education and experience
·  Minimum of two years Medicaid experience or other health care experience preferred
·  Active RN or LPN license in Kansas

Essential Functions:

·  Ability to make claims payment determination
·  Strong oral/written communication skills
·  Ability to read, understand, and interpret complex regulatory and procedural documents
·  PC skills
·  Demonstrates strong writing skills
·  Time management and organizational skills
·  Ability to work independently without frequent supervision
·  Strong analytical skills
·  Ability to successfully interact with other departments