Authorization Nurse - RN

Job ID
Clinical - All


To support and assist in maintaining medical management activities in the authorization process of outpatient, therapy and diagnostic services


Principal Responsibilities

  • Available as a resource for consults and questions from both clinical and non-clinical staff within Medical Management Operations
  • Fulfills supervisor duties in their absence
  • 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 license



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

  • Diploma or degree in Nursing
  • Current license to practice as a RN in the State of Louisiana
  • 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
  • Experience working with computers including EMR's
  • Knowledge of CMS guidelines and home bound status preferred.
  • Understanding of POC/485 clinical documentation preferred
  • MS Office knowledge preferred


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