HFHP Prior Authorization Nurse Specialist Senior

POSITION SUMMARY

Subject matter expert (SME) for clinical staff involved in the Health Plan’s prior authorization process including preservice, concurrent and post-service reviews. Expert in all areas of clinical review including but not limited to inpatient reviews, outpatient reviews and post-service reviews. 

PRIMARY ACCOUNTABILITIES

1. Intermediate to expert knowledge of all authorization review types that the Prior Authorization department is responsible for. This includes but is not limited to outpatient reviews, inpatient reviews, and post-service reviews. 
2. Accurately process authorization requests in accordance with member contract provisions, Medical Policies, departmental policies and procedures, and other plan approved guidelines (i.e. CMS, MCG, Hayes).
3. Expert in out-of-network authorization reviews with a large majority of their workload encompassing these types of reviews.
4. Department liaison that works with other Health Plan departments (i.e. Case Management) to ensure member care continuum is seamless. This involves referrals to Case Management department to assist with transitioning members that are utilizing out-of-network services to an in-network provider.
5. Work with other Senior Prior Authorization Specialists within the department to ensure all aspects of member care are met regarding authorization needs. This includes but is not limited to ensuring all discharge needs of the member (i.e. home care services, durable medical equipment, etc.) are met prior to discharge from inpatient facility.
6. Partner with appropriate professionals to ensure strict adherence to the boundaries and timeframes set by regulatory standards and accreditation guidelines.
7. Demonstrate advanced knowledge of accreditation and regulatory Utilization Management and Case Management standards and requirements.

MINIMUM QUALIFICATIONS

• Education: Associates Degree 
• Licensure: Unrestricted Florida Nursing License (LPN or RN)
• Work Experience: 

1. 1 year as a Prior Authorization Nurse Specialist within Health First Health Plans 
2. Clinical Operations Department with direct experience with out-of-network authorization requests. 
3. 3 years of direct patient care.

• Knowledge/Skills/Abilities: 

1. Intermediate knowledge of MHK utilization review system, Support Point, Amisys, MCG, Optum EncoderPro, and Hayes. 
2. Intermediate knowledge with all aspects of Microsoft Office – Outlook, Word, Excel, PowerPoint. 
3. Advanced understanding of procedural and diagnosis codes, claims payment rules, and electronic medical records.

PREFERRED QUALIFICATIONS

• Education: Associates Degree
• Licensure: Unrestricted Florida Nursing License (LPN or RN)
• Work Experience: 

1. 2 years of prior authorization experience as Prior Authorization Nurse Specialist within Health First Health Plans with extensive out-of-network review knowledge 
2. 5 years of direct patient care preferably within multiple specialties (i.e. Med/Surg, Pediatrics, Ortho, Case Management, SNF)

• Knowledge/Skills/Abilities: 

1. Excellent time management skills
2. Attention to detail
3. Excellent oral and written communication skills.

 PHYSICAL REQUIREMENTS

• Sedentary work involves sitting most of the time or standing at a stand-up style desk.
• Walking or lifting more than 10 pounds are required only occasionally.
• Must be able to tolerate long periods of computer time a day.
• Must be able to communicate effectively via telephone and electronically (i.e. instant message, email).
• This position may be a work-from-home position or work from office position depending on specific.
• departmental needs. Candidates would be expected to work from the office a minimum of 2 days per week.

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.