Medi-Cal Prior Authorizations LVN

JOB SUMMARY:

This position is for a California Licensed Nurse whose primary responsibilities are to perform the prospective and retrospective review of requests for service authorizations,
specializing in Medi-cal, in order to monitor continuity and coordination of care and to assist in the utilization of appropriate services. The Prior Authorization Nurse conducts
prospective and retrospective reviews of authorization requests including selected specialties, medical treatments and services, elective hospital admissions, rehabilitative
and ancillary services, home care and out-of-plan referrals. Assists with complex cases and internal process development. Interacts with the Prior Authorization Coordinators
to direct appropriate utilization and data capture.

SPECIFICS

  1. Determines compliance to pre-established medical necessity criteria applying Milliman, and Healthcare Management Guidelines.

  2. Suggests alternative treatment/service appropriate to the patient’s condition after reviewing with the UM Manager or Medical Director.

  3. Identifies cases requiring potential or actual use of medically inappropriate interventions and refers to Medical Director for review. 

  4. Processes at a minimum

        1. 55 authorization requests/per day with a 98% accuracy level and take up to 20 calls a day, or

        2. 65 authorization requests per day with 95% accuracy and take up to 20 calls per day, or

        3. 70 authorization requests per day with 95% accuracy and take not more than 5 calls per day.

  5. Interacts with providers for medical information necessary to adjudicate authorization. 

  6. Reviews each authorization if clinical history supports service/procedure requested. 

  7. Reviews each authorization for appropriate requested provider for service area.

  8. Reviews any potential denial of service with Medical Director.

  9. Investigates and follows up on all additional requests for information by UM Manager or Medical Director.

  10. Primary interface with the physician on urgent/emergent authorization requests. 

  11. Identify and report to Quality Management Department any potential quality of care issue and/or pre-established U.M. Referral Indicators. 

  12. Clinical resource for Prior-Authorization Coordinators. 

  13. Educate practitioners as needed with the Authorization/Referral process. 

  14. Respond to health plan inquiries and requests, and report and submit all pertinent data in a timely manner. 

  15. Collaborate with health plan case managers. 

  16. Maintains confidentiality of all patients and medical/clinical information. 

  17. Performs other functions as necessary to accommodate departmental change, workload and emergencies.

  18. Assists in the development, review and revision of departmental policies and procedures. 

  19. Ensure the privacy and security of PHI (Protected Health Information) as outlined in AMM policies and Procedures relating to HIPAA compliance.

  20. Understanding of all Medical Management Policy and Procedures, and NCQA guidelines. 

  21. Follow organizational chain of command. 

  22. Performs other duties as directed by management.

KNOWLEDGE, SKILLS & ABILITIES


1. Language & Communication Skills

  1. Service-oriented attitude is necessary; must be consistently friendly and attentive.

  2. Ability to read and comprehend simple instructions, short correspondence, and memos.

  3. Ability to write simple correspondence.

  4. Must be able to communicate both orally and in writing.

  5. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

  6. Willing to build productive relationships with all levels of staff

2. Mathematical Skills

  1. Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.

  2. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.


3. Reasoning Ability

  1. Ability to define problems collects data, establish facts, and draw valid conclusions.

  2. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.


4. Decision Making

  1. Recognizes and properly handles confidential health information.

  2. Able to efficiently prioritize multiple high-priority tasks.


5. Computer Skills

  1. To perform this job successfully, an individual should have knowledge of the Internet, MS Word and Excel.

  2. Knowledge of standard office machinery (fax machine, photocopiers, phones) necessary.

  3. Willingness and capacity to learn new software tools when necessary.

 

EDUCATION, TRAINING & EXPERIENCE

  1. Graduate from an accredited Nursing Program

  2. Current CA LVN license.

  3. One to two years related experience and/or training; or equivalent combination of education and experience

  4. Experience using Milliman Criteria

  5. Typing 40 words per minutes with accuracy.

  6. Knowledge of computers, faxes, printers and all other office equipment.

  7. Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)