Prior Authorization Nurse I
Posted on: 16 Feb 2021
Detroit, MI
Job Description
Position Purpose:
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* Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests
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* Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
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* Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
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* Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
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* Educate providers on utilization and medical management processes
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* Provide clinical knowledge and act as a clinical resource to non-clinical team staff
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* Enter and maintain pertinent clinical information in various medical management systems
Education/Experience:
Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2+ years of clinical nursing experience. Knowledge of healthcare and managed care preferred.
Licenses/Certifications: Current State LPN/LVN or RN license.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
title:Prior Authorization Nurse I
WellCare
Tampa, FL
WellCare Health Plans, Inc. provides government-sponsored managed care services. The company operates in three segments: Medicaid Health Plans, Medicare Health Plans, and Medicare Prescription Drug Plans (PDPs). The Medicaid Health Plans segment offers plans for beneficiaries of temporary assistance for needy families, supplemental security income, and aged blind and disabled residents; and other state-based programs, such as children's health insurance programs and long-term services and supports programs for qualifying families who are not eligible for Medicaid.
The Medicare Health Plans segment provides Medicare, a federal program that provides eligible persons aged 65 and over, as well as some disabled persons with a range of hospital, medical, and prescription drug benefits; Medicare Advantage, a Medicare’s managed care alternative to the original Medicare program, which offers individuals standard Medicare benefits directly through Centers for Medicare & Medicaid Services; and coordinated care plans that are administered through health maintenance organizations and require members to seek health care services and select a primary care physician from a network of health care providers.
The Medicare PDPs segment provides Medicare part D PDP plans to Medicare-eligible beneficiaries. Its PDP plans offer national in-network prescription drug coverage, including a preferred pharmacy network. As of December 31, 2018, the company served approximately 5.5 million members in the United States. WellCare Health Plans, Inc. was founded in 1985 and is headquartered in Tampa, Florida.
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IndustryHealthcare
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No. of Employees12, 000
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Website
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Jobs Posted917
