Parkland Community Health Plan's (PCHP's) Prior Authorization Nurse is responsible for providing timely review of authorization requests and ensuring the request meet national standards and contractual requirements. Promotes the quality and cost effectiveness of patient care using clinical acumen. Prepares documentation, performs audits of member records and assist management as needed.
- Must be a graduate of an accredited school of nursing.
- Bachelors degree in nursing is preferred.
- Three years of experience in an acute clinical nursing or medical management setting.
- Knowledge of utilization management and case management principles is preferred.
- Knowledge of Texas Medicaid requirements is preferred.
- Three years managed care experience is preferred.
Equivalent Education and/or Experience
- May have an equivalent combination of education and experience to substitute for the experience requirements.
- Must have current, unrestricted RN license to practice Nursing in the state of Texas (or compact license).
Skills or Special Abilities
- Clear and professional verbal and written communication skills.
- Proficient in Microsoft Word, Excel and Power point.
- Competent in prior authorization functions including application of criteria and timelines.
- Ability to analyze clinical information and accurately apply clinical criteria.
- Proficient in medical and managed care terminology.
- Knowledge of and competence in use of prior authorization software.
- Knowledge of NCQA, Federal and Texas Medicaid authorization regulations.
- Ability to multitask between computer, fax and multi-line phone requests.
- Promotes the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
- Performs clinical reviews of prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate medical director with recommendations for other determinations.
- Completes medical necessity and level of care reviews for requested services using clinical judgment and refers to medical director those that require additional expertise.
- Provides accurate and complete documentation with rational that was used to approve requests.
- Identifies members that are high risk or have conditions that may need case or disease management.
- Collaborates with various staff within provider network and health services team to coordinate member care.
- Maintains authorization turn-around times as prescribed by guidelines.
- Enters and maintains pertinent clinical information in health management system.
1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth
Job Segment: Nursing, Medical, Patient Care, Registered Nurse, Medicaid, Healthcare