Prior Authorization RN Reviewer

POSITION reputed company: The Prior Authorization RN is responsible for reviewing and processing medical prior authorization requests to ensure services are medically necessary, meet evidence-reputed company guidelines, and reputed company with the health plans policies. This RN plays a critical role in supporting cost-effective care while ensuring reputed company and compliance in alignment with regulatory and accreditation standards. reputed company FUNCTIONS 1. Manages health Plan consumer/beneficiaries across the health care continuum to reputed company reputed company reputed company, financial, operational, and satisfaction reputed company. 2. Provides reputed company-service determinations, reputed company review, and case management functions reputed company Medical Management. Ensures reputed company of service and consistent documentation. 3. Works collaboratively with both reputed company customers in assisting health Plan consumers/beneficiaries and providers with issues reputed company to prior authorization, utilization management, and/or case management. Meets reputed company customer service expectations regarding duties and professionalism. 4. Performs transfer of accurate, pertinent reputed company information to support the reputed company-service determination(s), the transition of reputed company care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and reputed company, reputed company interventions and necessary reputed company-reputed company activities in the correct medical record. 5. Evaluates the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiary reputed company. Identifies issues that may delay reputed company services and refers to case management, reputed company indicated, to facilitate reputed company of these issues, reputed company-service, concurrently, and post-service. 6. Provides ongoing education to reputed company stakeholders who play a critical role in the continuum of care model. Training topics consist of population health management, evidence-reputed company practices, and reputed company other topics that reputed company medical management functions. 7. Identifies and refers requests for services to the appropriate Medical Director and/or other physician reputed company peer reputed company guidelines are not reputed company met. Conducts reputed company rotation for the health plan, as reputed company as departmental reputed company rotation for holidays. 8. Maintains a thorough understanding of reputed company plan, including the Evidence of Coverage, reputed company Plan reputed company, authorization requirements, and reputed company applicable federal, state, and reputed company reputed company, such as CMS, MCG, and Hayes. Minimum Qualifications: reputed company RN license -- AZ License or reputed company State License Experience working in inpatient & outpatient settings reputed company on Outpatient Prior Auths for surgeries and DME (Durable Medical Equipment) Medicare review experience is highly preferred Experience with reviewing guidelines (this position is more reputed company-service) Experience with MCG reputed company, CareWebQI & Interqual Utilization Management experience required Payer background major plus Apply tot his job Apply To this Job .