Under the direction of the Medical Management Director, Sr Manager and Medical Director, this position is responsible to process health plan medical prior authorization requests, provide case management, care coordination and perform utilization management duties within the appropriate time period as outlined in the BPA and UAHP Medical Management Program Descriptions, and in accordance with all federal and state regulations.
Participates in duties to support prior authorization, concurrent review, and case management within Medical Management. Ensures quality of service and consistent documentation.
Performs transfer of accurate, pertinent patient information to support the prior authorization of services, the transition of the patients needs during transitions of care, and perform follow-up discharge calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient related activities in the correct medical record.
Works cooperatively with both internal and external customers in assisting members and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.
Conducts call rotation for the health plan, as well as departmental call rotation for holidays.
Maintains a thorough understanding of accreditation standards and of CMS standards for determination of the medical necessity of services requested.
Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes. Identifies issues that may delay patient services and refers to case management, when indicated to facilitate resolution of these issues, pre-service, concurrently and post-service.
Maintains a thorough understanding of each plan, including the Evidence of Coverage, authorization requirements, and all applicable federal, state and commercial criteria, such as CMS, AHCCCS, MCG, and Hayes.
Performs other related duties as assigned, which are consistent with the goals and qualifications of this position.
Current, unrestricted Arizona Licensed Practical Nurse (LPN) license permitting work in the State of Arizona. A minimum of three years of experience in an acute care setting. At least two years of experience in prior authorization, utilization management, or case management.
Concurrent and retrospective data management skills are necessary. Working knowledge of medical terminology and coding (ICD-9/10, CPT-4) is required. Computer, data entry and word processing skills, as well as excellent written and verbal communication skills. Must have a working knowledge of care management, prior authorization, hospital and community resources, and utilization management. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format, Must be able to work flexible hours and may need to take rotating call after hours.
Proficient on a computer (PC) with Microsoft Office Products. Ability to work with data bases/programs, and ability to work independently, with analytical, problem solving, decision making.
Experience specific to Med/Surg, managed care and knowledge of Federal and State programs as well as Commercial plans. Working knowledge of clinical criteria such as MCG (Milliman) or InterQual is preferred.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.