RN Referral Management Coordinator (Virtual) - Prior Authorizations - 40 Hours - Day Shift - HAP Health Alliance Plan

RN REFERRAL MANAGEMENT COORDINATOR (VIRTUAL) - PRIOR AUTHORIZATIONS - 40 HOURS - DAY SHIFT

Full Time Benefit Eligible

Schedule: Monday through Friday, 8:00AM to 4:30PM, Remote

General Summary

Unit Description:

Health Alliance Plan (HAP) is looking to grow our Prior Authorization Team with experienced Registered Nurses! We are a team of Registered Nurses (5 and counting), and Administrative Professionals (3) that review medical necessity and medical criteria for all prior authorizations within our system in partnership with our Medical Director. If you are computer savvy, have a strong work ethic and attention to detail, and are looking to move away from bedside care, this is the team for you!

• Processes referral requests by verifying network assignment, correct provider, applying criteria to determine clinical appropriateness, and assessing level of care requirements.
• Coordinates peer-to-peer conversations with the Medical Director and provider at the time of the request.
• If the Medical Director denies the request, follows denial processing according to the policy. Processes a provider denial letter based on the rationale of the Medical Director at the time of the denial and distributes to the Utilization Management Services staff for processing.
• Reports on potential quality of care issues to the Quality Management Department for further investigation and validation. Tracks physician non-compliance with UM Policies & Procedures and report to QM Department via physician profiling procedures.
  
  

This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and duties. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described above.

Education/Experience Required

• Nursing Diploma, required.
• Bachelor's Degree in Health Care or related field, preferred.
• Minimum of two (2) years of recent clinical management of patients in an inpatient or ambulatory setting, or at least two (2) years of experience in Utilization or Quality Management, required.
  
  

Certifications/Licensures Required

• Registered Nurse (RN) with current Michigan licensure.
  
  

Additional Information

• Organization: HAP (Health Alliance Plan)
• Department: Prior Authorizations
• Henry Ford Health Location: HAP (Health Alliance Plan)
• Shift: Day Job
• Union Code: Not Applicable