Prior Authorization RN

Position Duties & Responsibilities

• Monitor the PA Nurse and Pharmacy Request queues as directed by prior authorization management, ensuring timely processing of Routine/Standard and Urgent/Expedited prior authorizations in compliance with regulatory and health plan requirements.
• Absorb authorization requests to ensure all necessary information is provided. If documentation is insufficient, actively obtain the required information to facilitate timely decision-making.
• Review requested services and apply the relevant health plan criteria hierarchy to locate guidelines that support the medical director in assessing medical necessity.
• Conduct clinical reviews for Prior Authorization (PA) Nursing in accordance with AZPC policies, applying relevant guidelines and criteria to determine the medical necessity of requested services, and approve requests when appropriate.
• Prepare authorization requests requiring review by Medical Directors, ensuring adherence to the appropriate SBAR (Situation, Background, Assessment, Recommendation) framework, Utilization Management review hierarchy, inclusion of necessary denial language, and completion of any additional research as required.
• Compose medical necessity denial letters using pre-service denial formats that comply with health plan and CMS requirements. Ensure adherence to all regulatory guidelines, including timely submission, and maintain clarity with a Flesch-Kincaid score of less than 8, while avoiding spelling and grammatical errors.
• Process a minimum of 20 prior authorization requests daily, depending on the complexity of each request.
• Achieve and maintain a clinical review accuracy rate of 98% or higher, ensuring high-quality assessments throughout the review process.
• Act as a liaison between the Medical Director and providers to address prior authorization concerns and inquiries.
• Maintain up-to-date knowledge of regulatory requirements established by CMS, NCQA, and Health Plans, including compliance standards and the defined scope of practice.
• Identify cases involving potential or actual medically inappropriate interventions and refer them to the Medical Director for review.
• Identify and report any potential quality of care issues to the Quality Department.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in Arizona Priority Care Policies and Procedures relating to HIPAA compliance.
• Provides excellent customer service skills with internal and external incoming and outgoing phone calls.
• Interacts professionally and communicates clearly with staff, other departments, management, providers, and members.
• Demonstrate flexibility to adjust to work assigned based on competing demands of the organization.
• Collaborate with the Quality department to conduct thorough reviews of medical records, ensuring compliance with standards and identifying potential areas for improvement.
• Assist in analyzing member surveys to gather insights on quality of care and patient satisfaction.
• Support the identification and investigation of potential quality issues to promote continuous improvement in services.

Education, Training And Experience

• Graduated from an accredited Registered Nurse Program.
• Current unrestricted AZ RN License.
• Minimum of 3 years acute care or care management experience.
• Knowledge of Medicare, state and local managed care regulations, prior experience in Managed Care setting preferred.
• Prior experience with record review and knowledge of record documentation standards.
• Exceedingly detail-oriented, able to function under pressure and prioritize and re-prioritize tasks as needed.
• Exceptional organizational and project management skills including strong attention to accuracy.
• Exceptional interpersonal, verbal and written communication skills, including proofreading and grammar skills.
• Able to communicate effectively and in professional manner with all levels of internal staff and external customers.
• Able to work both independently and as part of a team, with minimal supervision.
• Proficient ability with multiple Microsoft Office applications (Word, Outlook, Excel, Power Point, etc.) and work within electronic health records systems, including NextGen and EzCap.