ICONMA
Our Client, a Medical Center company, is looking for a Prior Authorization RN for their Charlestown, MA location.
Responsibilities
Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination.
Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.
Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria
Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.
Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).
Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.
Sends appropriate system-generated letters to provider and member
Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
Follows all departmental policies and workflows in end-to-end management of cases.
Participates in team meetings, education, discussions, and related activities
Maintains compliance with Federal, State and accreditation organizations.
Identifies opportunities for improved communication or processes
May participate in audit activities and meetings
Documents rate negotiation accurately for proper claims adjudication
Identify and refer potential cases to Care Management
Requirements
Nursing degree or diploma required, bachelor’s degree in nursing
Medicare and Medicaid knowledge
2+ years prior authorization experience and evidence-based guidelines (InterQual Guidelines)
Managed care experience
Active RN license for the state of employment
Why Should You Apply?
Health Benefits
Referral Program
Excellent growth and advancement opportunities
As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, gender, sexual orientation, gender identity or express, ethnicity, national origin, age, disability status, political affiliation, genetics, marital status, protected veteran status, or any other characteristic protected by federal, state, or local laws.
#J-18808-Ljbffr
Responsibilities
Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination.
Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.
Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria
Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.
Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).
Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.
Sends appropriate system-generated letters to provider and member
Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
Follows all departmental policies and workflows in end-to-end management of cases.
Participates in team meetings, education, discussions, and related activities
Maintains compliance with Federal, State and accreditation organizations.
Identifies opportunities for improved communication or processes
May participate in audit activities and meetings
Documents rate negotiation accurately for proper claims adjudication
Identify and refer potential cases to Care Management
Requirements
Nursing degree or diploma required, bachelor’s degree in nursing
Medicare and Medicaid knowledge
2+ years prior authorization experience and evidence-based guidelines (InterQual Guidelines)
Managed care experience
Active RN license for the state of employment
Why Should You Apply?
Health Benefits
Referral Program
Excellent growth and advancement opportunities
As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, gender, sexual orientation, gender identity or express, ethnicity, national origin, age, disability status, political affiliation, genetics, marital status, protected veteran status, or any other characteristic protected by federal, state, or local laws.
#J-18808-Ljbffr