HFHP Prior Authorization Nurse Specialist - Clinical Operations

POSITION SUMMARY

To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by

performing responsibilities associated with a sustainable, measurable, accurate, reliable and timely

execution of the Prior Authorization Process. Success in this position will be based on the individual's

ability to effectively prioritize and manage requests in an accountable and responsible manner and

consistently meet departmental metrics of production and quality.

PRIMARY ACCOUNTABILITES

1. Accurately processes prior authorization requests per member contracts, policies, and CMS guidelines, and refer cases to the Medical Director when necessary.

2. Provides accurate, sensitive, and timely support to customers regarding authorizations, benefits, eligibility, and claims.

3. Maintains confidentiality and adheres to HIPAA, regulatory standards, and accreditation guidelines.

4. Achieves individual productivity and quality goals, contributing to departmental performance metrics.

5. Records authorizations, perform data entry in Medical Management Systems, and document decisions per established protocols.

6. Conforms to defined roles, responsibilities, and decision-making boundaries between authorization processing and clinical decisions.

7. Utilizes Health First Health Plan resources efficiently, recommending care alternatives to streamline costs and improve clinical outcomes.

8. Finds and refers to complex cases for potential case or disease management intervention to improve patient outcomes.

9. Evaluates cases for quality of care, document issues, and refer cases with potential quality concerns as per policy.

10. Identifies and communicate opportunities to reduce medical expenses and triage concerns accurately.

11. Engages in special projects aimed at reducing administrative costs and improving process efficiency.

12. Ensures a clean, safe work environment

MINIMUM QUALIFICATIONS

• Education: Licensed Practical Nurse Diploma
• Work Experience:
• Three (3) years’ experience in direct patient care setting.
• Two (2) years’ experience in Managed Care.
• Licensure: Current unrestricted LPN Licensure in the State of Florida.
• Certification: None
• Skills/Knowledge/Abilities:
• Excellent attention to detail and quality of work.
• Advanced computer skills (e.g. navigation and workflow within EMR.
• Benefit Administrations systems or medical management applications knowledge including Microsoft Office Applications).
• Ability to work tactfully and effectively with team members, vendors and providers.

PREFERRED QUALIFICATIONS

• Education: Associate of Science in Nursing.
• Work Experience:
• Five (5) years’ experience in a direct hospital setting.
• Two (2) years’ experience in Medicare Managed Care, and Prior Authorization.
• Licensure: Current unrestricted RN Licensure in the State of Florida.
• Certification: Certified Case Manager (CCM).
• Skills/Knowledge/Abilities:
• Excellent Oral and written communication skills.
• Excellent time management skills.
• Knowledge of Milliman Care Guidelines (MCG), Optum EncoderPro, Hayes and EPIC EMR systems.
• Advanced understanding of procedural and diagnosis coding.
• Knowledge of insurance claims processing related to authorizations.

PHYSICAL REQUIREMENTS

• Majority of time involves sitting or standing; occasional walking, bending, and stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined, onsite, or remote.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle