What are the responsibilities and job description for the Remote Prior Authorization Nurse position at Hill Physicians Medical Group?
We are currently have five (5) immediate openings for Prior Authorizations UM Nurse, must have an Unrestricted California RN license to be considered, 100% remote opportunity.
Company Overview
Hill Physicians Medical Group is the largest Independent Physicians Association in Northern California, dedicated to providing high-quality healthcare across the San Francisco Bay, Sacramento, and Central Valley areas. With over 5,700 primary care physicians and specialists, we have been a cornerstone of the Northern Californian healthcare community for 40 years, committed to diversity and inclusion.
Summary
We are seeking a dedicated UM Prior-Authorizations RN Nurse to join our team at Hill Physicians Medical Group. In this role, you will provide exceptional patient care and support within our diverse healthcare environment. Your contributions will be vital in ensuring our patients receive the highest quality of care.
Evaluate authorization requests and authorize, modify or pend per appropriate criteria. Refer authorization requests not meeting criteria to specialty physician reviewer according to established medical necessity, benefit and eligibility criteria to assure appropriate, efficient and timely medical care.
Job Responsibilities
- Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.
- Obtain additional medical information as necessary from requesting provider.
- Communicate with providers and members regarding status of authorization requests.
- Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.
Additional Responsibilities
- Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions. Criteria may include Milliman Care Guidelines, Hill Guidelines, Health Plan Criteria, Health Plan and Hill Physician contracted provider data and member benefit information.
- Obtain additional medical information as necessary from requesting provider.
- Communicate with providers and members regarding status of authorization requests.
- Assist interdepartmental staff members to resolve issues relating to the authorization process.
- Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).
- Process authorization requests (routine, urgent and retrospective) according to department performance standards.
- Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.
- Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.
- Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.
- Perform other duties as assigned by supervisor/manager.
- Assist interdepartmental staff members to resolve issues relating to the authorization process.
- Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).
- Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.
- Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.
Required Experience
- Minimum three years clinical nursing experience.
- Utilization Management experience preferred.
- Excellent verbal and written communication skills.
- Ability to work effectively with a variety of customers including physicians, office staff, and members.
- Ability to work independently with self-initiative and discipline.
- Working knowledge of personal computers.
- Managed care experience and certification preferred.
- Knowledge of ICD-10 and CPT coding.
- Optimum organizational skills with ability to meet expected and unexpected time frames.
Required Education
Active, unrestricted California Licensure: Registered (RN)
Additional Information
Salary: $ 100,000 - $120,000 Annual
Job Type: Full-time
Pay: Up to $115,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee discount
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Parental leave
- Professional development assistance
- Retirement plan
- Tuition reimbursement
- Vision insurance
Medical Specialty:
- Home Health
- Medical-Surgical
- Telemetry
Physical Setting:
- Inpatient
- Outpatient
Supplemental Pay:
- Yearly bonus
Application Question(s):
- Do you have prior authorizations experience and utilization management?https://primed.wd1.myworkdayjobs.com/PriMed/job/Sacramento-California/Authorization-Nurse--RN---25-70_R2150
License/Certification:
- Unrestricted Active California RN License (Required)
Work Location: Remote
Salary : $100,000 - $120,000
