Centrum Health · 1 day ago
UM Prior Authorization Nurse, RN (Work from Home)
United States
Full-time
Remote
Entry, Mid Level
$74K/yr - $111K/yr
2+ years expNeueHealth is a value-driven healthcare company committed to providing high-quality, coordinated care. The UM Prior Authorization Nurse is responsible for promoting quality and cost-effective outcomes by ensuring appropriate benefit coverage for services requiring prior authorization and collaborating with the clinical team.
DentalHealth CareHospitalMedicalPrimary and Urgent Care
Responsibilities
Evaluate and process prior authorization requests for medical procedures, medications, and services based on clinical guidelines such as: Medicare criteria, Medicaid/Medi-Cal criteria, InterQual, MCG, or Health Plan specific guidelines
Utilize clinical knowledge to assess medical necessity and appropriateness of requested services
Verify patient eligibility, benefits, and coverage details
Serve as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process
Communicate authorization decisions to the requesting provider and/or patient in a timely manner
Provide detailed explanations of denials or alternative solutions when authorization is not granted
Collaborate with the Medical Directors as needed to ensure all information is considered prior to an adverse determination
When an adverse determination is rendered, collaborate with the Medical Director to ensure integrity of determination notices based on the quality standards for adverse determinations
Comply with federal, state, and health plan specific requirements related to member communication of adverse determinations to include preferred language, mandated readability standard, correct medical criteria is referenced and the appropriate appeal information is provided
Accurately document all authorization-related activities in the electronic medical record (EMR) or authorization management system
Ensure compliance with federal, state, and health plan specific regulations and guidelines
Maintain knowledge of evolving policy and clinical criteria
Identify trends or recurring issues in authorization denials and recommend process improvements
Participate in team meetings, training sessions, and audits to ensure high-quality performance
Qualification
Required
Active California license as a Registered Nurse (RN)
Minimum 2 years of clinical nursing experience, preferably in utilization management, case management, or prior authorizations
Strong analytical and critical thinking skills to assess medical necessity
Proficient in medical terminology and pharmacology
Effective written and verbal communication skills
Ability to work independently and collaboratively in a fast-paced environment
Highly adaptable to change and self-motivated
Experience with EMR systems and prior authorization platforms
Proficient in Microsoft Office Suite (Word, Excel, Outlook)
Preferred
Bachelor of Science in Nursing (BSN)
Certification Managed Care Nursing (CMCN)
Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes)
Working knowledge of MCG, InterQual, and NCQA standards
Benefits
Health benefits
Life and disability benefits
401(k) savings plan with match
Paid Time Off
Paid holidays
Company
Centrum Health
Centrum Health provides medical, primary care, dental care, diagnostic, and laboratory services.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Tomas Orozco
Chief Executive Officer
Carlos A. Fernandez-D’Mant
Executive Vice President , Chief Growth Officer
Recent News
2024-04-10
Company data provided by crunchbase