Prior Authorization Lead Nurse - RN/LPN - Remote FL

Profile

Description

The Pre-Authorization Nurse 1 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 1 work assignments are often straightforward and of moderate complexity.

Responsibilities

The Pre-Authorization Nurse 1 completes medical necessity and level of care reviews for requested services using clinical judgment, and refers to internal stakeholders for review depending on case findings.


Educates providers on utilization and medical management processes.
Enters and maintains pertinent clinical information in various medical management systems.
Understands own work area professional concepts/standards, regulations, strategies and operating standards.
Makes decisions regarding own work approach/priorities, and follows direction.
Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation.
Participation in work groups
Assist with training new team members; and provide re-education with existing team
Assist with monitoring department processes and reports
Will work closely with leadership team to identify process improvement opportunities


Required Qualifications


Active Unrestricted LPN or RN license in the state of Florida in which the nurse is required to practice
3 or more years varied nursing experience
1 year prior authorization experience
Proficient with MS Office products including Word, Excel and Outlook
Ability to work independently under general instructions and with a team
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Must be able to work Monday - Friday 8:00 - 5:00 PM; with flexibility with rotating on-call coverage and oversight during weekends and holidays.


Work At Home Requirements


Must have a separate room with a locked door that can be used as a home office to ensure you and your members have absolute and continuous privacy while you work.
Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.


Preferred Qualifications


Health Plan experience working with large carriers
Previous Medicaid experience a plus
Experience working with MCG


Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate in a Montage Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

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