Affinity has an exiciting opportunity for a Pre-Certification Nurse. This position will be responsible for using evidenced based criteria sets and or Healthplan criteria to review provider requests for prior authorization of outpatient and inpatient services for commercial and Medicare product lines.
Specific Duties and Responsibilities
- Conducts prospective and retrospective authorization review for up to 50 cases per day
- Ensures services authorized are covered benefits and medically necessary
- Clearly documents medical determinations, citing criteria used to make determinations
- Forwards potential denials and services requiring physician review to the assigned medical director
- Conducts pre-service education calls to members for selected services
- Conducts provider outreach and education as relates to the authorization process and redirection of services
- Writes pre-service and post service denial reasons in a timely and efficient manner, facilitating the production of regulatory notice requirements
- Coordinates with health plan contacts to resolve appeals/grievances, out of area services and carved-out services
- Conducts back-up onsite or telephonic review of inpatient admissions and or case management outreach activities
- Assists with other duties as assigned
- Licensed RN or LPN with a strong working knowledge of clinical criteria sets such as CMS local and national guidelines, Milliman criteria, and Interqual criteria.
- Minimum 5 years in a medical setting, Healthplan or medical group setting preferred
- Prior precertification experience required
- Experience working with Healhplans, IPAs, physician offices, ancillary vendors and and hospitals
- Ability to read and interpret healhplan contracts/DOFRs, medical policy gidelines
- Good typing/documentation and business grammar are a MUST
- Strong communication skills (verbal & written) – excellent telephone communication ability is a MUST
- Computer skills, including word processing, required.
- Comfortable using/searching health-plan and government websites