Job Details
Location: Required: AZ Residency and AZ License
Shift: 8-5 Mon-Friday-flexible start time, OT available but not required.
Requirement: Nurse would require and RN License in AZ
"Social Worker/ Counselor Requires a Master s degree and AZ license
Job Description: Position Purpose:
Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor s degree in Nursing and 2
4 years of related experience.
Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
Requirement: Nurse would require and RN License in AZ
"Social Worker/ Counselor Requires a Master s degree and AZ license
Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
Assists with service authorization requests for a member s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collects, documents, and maintains all member s clinical information in health management systems to ensure compliance with regulatory guidelines
Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
Provides feedback on opportunities to improve the authorization review process for members
Performs other duties as assigned
Walk me through the day-to-day responsibilities of this the role and a description of the project:
Behavioral Health and Psychiatric Exp required!
Reading treatment plans and making determinations
Must have experience with all ages (pediatrics to geriatrics)
Coordinate with providers via email and phone
Experience as a Review Nurse (remotely)
Experience with Prior auth
Would accept an RN with Behavioral/Mental and Psychiatric health experience or would accept a Licensed Social Worker/Licensed Professional Counselor
Navigating multiple systems
Reviewing Medical Records.
What previous job titles or background work well in this role?
License Social Worker, License Professional counselor, RN -Behavioral Health/Psychiatry
If candidate is a Nurse- would require and RN License in AZ
Social Worker/ Counselor Requires a Master s degree and AZ license
Internal/External Groups with which the Candidate will interface:
Required Skills/Experience:
Preferred Skills/ Experience:
1.Behavioral Health and Psychiatric Exp required1.
2.Exp as a Review Nurse2.
3.Prior Auth exp3.
Education Requirement:"Nurse would require and RN License in AZ
"Social Worker/ Counselor Requires a Master s degree and AZ licenseEducation Preferred: