Authorization Nurse - Licensed Practical Nurse (LPN)

Job ID
Clinical - All


To support and assist in maintaining medical management activities in the authorization process of outpatient, therapy and diagnostic services. The authorization Nurse will have responsibilities to maintain and ensure alignment with the mission of Peoples Health as outlined in the mission statement.



Principal Responsibilities

  • Responsible for reviewing authorization requests against InterQual criteria, CMS guidelines and Peoples Health policies
  • Responsible for data entry of requests and additional documentation tracking of requests in CCMS and Macess
  • Responsible for complete and accurate documentation of medical necessity for services
  • Initiates Care Coordination (Nurse Practitioners, MSW and RN) referrals for members when necessary
  • Enters authorization data into CCMS for Home Health and Outpatient Wound Care requests
  • Responsible for assisting Market Teams in issuing authorization numbers to Home Health agencies when appropriate and approved
  • Communicates with Medical Management Manager and Medical management Supervisor on a regular basis reviewing outstanding authorization requests
  • Assist in the resolution of issues/problems to provide the member with adequate care
  • Coordination and cooperation with Health Services staff regarding inquiries and entry of requests into CCMS
  • Complete information required for medical review process and extension letters
  • Processes CSFs and ISFs on a daily basis
  • Reviews Authorization requests and associated clinical information received via fax and processes and documents according to PH process and training documents
  • Assists in filing appropriate information into the member file as directed
  • Follows all policies and procedures regarding authorization process, organizational determinations, medical review, medical director review and other relevant medical management policies and procedures
  • Knowledge of individual plans administered by Peoples Health network
  • Responsible for tracking information being requested and assuring that the established time frames for medical management decisions are being adhered to
  • Responsible for issuing authorization numbers to the providers when appropriate and approved
  • Responsible for oversight and follow-up to non-clinical staff for any clinical related question or isue involving an authorization
  • Reports any problem that non-clinical staff has with authorizations to the supervisor within the dame day of the issue
  • Clinical staff performing initial clinical review has immediate access to the Medical Directors for consultation on any clinical related question or issue under medical review
  • Participates in Medical Management Team and departmental meetings
  • Participates in the Orientation Program for new employees
  • Responsible for ensuring that quality outcomes set by the department's leadership is consistently met to maximize member experiences with service delivery
  • Assists in the resolution of claims pended in the system
  • Log into phone queue to accept telephone inquiries from providers or their office staff regarding notifications or authorization numbers
  • Completes Member Appeal Letters when necessary
  • Performs all other duties as assigned by the MMO Supervisor or Manager, AVP of MMO and/or Senior VP of Health Services within scope of required licenses.



Core Competencies

  • Professionalism
  • Strong verbal and written communication skills
  • Ability to effectively interact with multifaceted medical professional staff
  • Pleasant and helpful attitude toward physician / physician's staff / PHN staff
  • Strong problem solving skills
  • Ability to multi-task

Experience / Education

  • Graduate of a Licensed Practical Nursing program
  • 1 -3 years in a Medical/Surgical experience or experience in a Managed Care/Insurance industry
  • Understanding of HMO/Third Party Administrator (TPA) plans highly preferred
  • Knowledge of CMS guidelines and home bound status preferred.
  • Understanding of POC/485 clinical documentation preferred
  • MS Office knowledge preferred


  • Current Louisiana LPN license required


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