RN-Prior Auth Nurse
Company: DaVita Medical Group
Location: Las Vegas
Posted on: October 12, 2018
RN-Prior Auth Nurse SUMMARY With minimal supervision, the UM Nurse is responsible to receive, review, verify, and process requests for diagnostic testing, inpatient admissions, outpatient procedures/testing, home health care, pharmacy pre-authorization and DME as applicable. The UM nurse will review prior authorization requests or level of care reviews for medical appropriateness by using established clinical protocols to determine the medical necessity of the request. UM nurses will utilize the following criteria in making a decision: A. Plan Eligibility and Coverage; B. Center for Medicare and Medicaid Services (CMS) - 1. National Coverage Determinations (NCDs), 2. Local Coverage Determinations (LCDs), 3. Local Coverage Medical Policy Articles, 4. Medicare Benefit Policy Manual; C. Health Plan Coverage Medical Polices; D. Milliman Care Guidelines (MCG); E. National Comprehensive Cancer Network Guidelines (NCCN), F. Diagnostic and Statistical Manual of Mental Disorders (DSM V), and G. American Society of Addiction Medicine (ASAM). The UM Nurse will collaborate with members of the management team and the Medical Director in determining medical necessity of service, level of care, length of stay and general appropriateness of care in the most cost effective, quality setting. Accountable for determining length of stays that meet established standards for well managed populations. The UM Nurse is accountable to investigate member history and eligibility as appropriate, contact case managers and UM Clinical Support Staff to gather further information, support the health plan needs to be cost effective and quality conscious, identify and report issues that may result in a grievance to ensure appropriate awareness, serve as a mentor to other team members, assist in training of prior authorization staff and assist in the development of policies and procedures. ESSENTIAL FUNCTIONS Responsible for quality and continuous improvement within the job scope. Responsible for all actions/responsibilities as described in company controlled documentation for this position. Contributes to and supports the corporation's quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation's quality improvement efforts. Receive, review and verify prior authorization requests. Reviews prior authorization requests with Medical Director and other team members as needed and appropriate. Collaborates with attending physician as necessary to obtain clinical information to assist in the prior auth request determination. Recommends, coordinates and educates providers and their offices on the need for complete patient information to make determination. Ensures the hospital, provider or facility have the appropriate in network vendor as needed by referring to the correct customer service number for the company group. Responsible for timely and accurate documentation in the computer system. Documentation will be compliant with established standards with established standards which are monitored through Inter-rater reliability audits. Responsible to document ICD-10 and CPT coding and levels of care to reflect care and services provided for claim adjudication. Successfully achieves 95% on all inter-rater reliability testing. Participates in internal audit reporting as necessary. Active participation in team meetings and case rounds. Assists in the development of policies and procedures. Maintains a courteous, professional attitude when working with facility staff, providers and their staff, the health plan and co-workers. Provides excellent customer service to internal and external customers. Cultivates, maintains, and enhances interdepartmental and staff relationships. Identifies and communicates to OP CM team all potential catastrophic and high risk cases for case management referrals. Committed to ALOS, bed day reductions and other departmental targets. Active participation in team meetings. Assists in the development of policies and procedures. Maintains a courteous, professional attitude when working with facility staff, providers and their staff, the health plan and co-workers. Provides excellent customer service to internal and external customers. The UM Nurse reports to the UM Manager. EXPERIENCE REQUIREMENTS At least two years experience in utilization review, high risk management, concurrent review, quality assurance, discharge planning or other cost management programs preferred. Experience using Federal, State, Health Plan, Milliman Guidelines or other hospital criteria preferred. Two years experience in direct patient care required and working knowledge of utilization management/case management preferred. EDUCATIONAL REQUIREMENTS Registered Nurse (RN or LPN) with current, unrestricted license in NevadaKNOWLEDGE, SKILLS, ABILITIES Possess a strong progressive and customer-focused approach to building and maintaining customer and patient relations and overall business success. Problem solving and decision making skills with good organization and attention to detail is required. Proficient in Microsoft Office - Word, Excel, Power Point, etc.
Keywords: DaVita Medical Group, Las Vegas , RN-Prior Auth Nurse, Healthcare , Las Vegas, Nevada
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