RN Job
Prior Authorizations, Case Manager (LVN/RN) – West Hills
Job Description
The role of the Prior Authorization Review Nurse, LVN/RN is to promote the quality and cost effectiveness of medical care by applying clinical judgement and the appropriate application of policies and guidelines to prior authorization referral requests.
The Prior Authorization Review Nurse, LVN/RN will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated. If not indicated, they will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed.
Qualifications
Education and/or Experience:
- Graduate from an Accredited Nursing Program
- Active California Licensed Vocational Nurse licenseMinimum of 1 year of processing prior authorization referrals experience
- Knowledge of Healthcare and Managed CareKnowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization
- At least 1 year of clinical experience (SNF, Home health, Hospital, etc)
- Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
- Typing 45 WPM with accuracy
- Ability to deal with responsibility with confidential matters
- Ability to work in a multi-task, fast-paced, high-stress environment
About the Hospital
As one of the largest physician-led networks in Southern California, we have thousands of physicians and hundreds of hospitals committed to providing quality healthcare to all of the communities we serve.
Every day, our employees are inspired to make a difference in the lives of others as well as transform their own experiences to achieve a higher sense of fulfillment. Our employees become a part of an extraordinary team of people dedicated to health, wellness, and happiness for themselves and others. There is no greater reward than contributing to a positive work environment where compassion, understanding, care and attention are encouraged and valued.
