RN Prior Authorization

Experience:

 Private Duty, Home Health, Pediatrics, Children Special Healthcare Needs (CSHCN), Chronic Care Professional (CCP), CPO3. 

• No direct patient care
• 8 hour shifts unless OT is needed and approved
• will have a shift between 7am and 7pm, so must be available for all shifts between that time. 
• The Registered Nurse conducts pre-service, concurrent/ retrospective reviews. 
• They will collaborate with healthcare providers to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 
• They will ensure medically appropriate, high quality, cost effective care through assessing the medical necessity of outpatient services, out of network services, and appropriateness of treatment setting within the scope of professional limitations by utilizing the applicable rules of the Texas Administrative Code (TAC), Texas Health and Human Services Commission (HHSC) approved medical policy, and industry standards, accurately interpreting benefits and managed care products. 
• They may educate providers on programs or community resources that may benefit the member. 
• The Registered Nurse will work with physicians in interpreting appropriateness of care. - Conducts pre-service, concurrent/ retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. 
• Service requests may be from electronic transmission, inbound calls and facsimile 
• Makes outbound calls to the provider as required to gather additional information that may be needed - Utilizes client specific criteria sets, applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to the clients nursing reviewer and/or clients medical staff for review 
• Conducts any utilization or medical management review activities which require the review of clinical information against client specific criteria as noted above, but excludes denial determinations - 
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract - Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process - 
• Collaborates with providers to assess members, needs for early identification of and proactive planning for discharge planning - 
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required - 
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting 

Qualifications

Texas Licensed Registered Nurse

Additional Information

All your information will be kept confidential according to EEO guidelines.