Review requests for prior authorization of medical services such as office visits, transportation, and elective and outpatient procedures and surgeries.
At least two years of clinical nursing experience. Experience with managed care and medical management software programs. Prior authorization, concurrent review, or case management experience preferred.
Licenses/Certifications: RN, LPN or LVN required. Current state nursing license.
- Review provider requests through fax, telephone, or web to ensure medical necessity for services requiring preauthorization. Input authorizations into applicable system
- Utilize nationally recognized criteria to determine medical necessity of services requested
- Refer provider requests appropriately to Medical Director when medical necessity of services is not met based on the criteria
- Act as a clinical resource to Referral Specialists
- Act as a liaison between providers and the Medical Director
- Direct members to contracted physicians, facilities and healthcare service providers
- Identify members that would benefit from case management to improve member’s needs
The position above is with Superior HealthPlan, a wholly owned subsidiary of Centene Corporation, located in Texas.
Superior HealthPlan is a leading multi-line healthcare organization that provides programs and related services to individuals receiving benefits under Medicaid, including enrollees in Temporary Assistance for Needy Families (TANF), the Children’s Health Insurance Program (CHIP), Supplemental Security Income (SSI)/Aged, Blind and Disabled (ABD), Foster Care and Medicare.
Superior HealthPlan offers competitive salaries and a broad range of comprehensive benefits to its employees. Some of those benefits are: Exemplary Health, Dental and Vision Insurance, 401(k) Retirement Plan, Employee Stock Purchase Plan, Tuition Reimbursement Program, and a generous Time Off policy.
Centene Corporation - 17 months ago
Centene is sensitive to the needs of individuals and families enrolled in government-assisted health programs. The company provides managed...