Prior Authorization Nurse - 241209 New

Medix is hiring for Prior Authorization Nurse for a Health Plan in CA. Must be able to train onsite in Chatsworth, CA. It will be fully remote after training is completed. The schedule is Monday - Friday 8:30a-5p. We are looking for someone that has previous Prior Authorization experience.

Training: Chatsworth, CA (3-4 weeks)

Job Overview

The UM Prior Authorization Nurse is primarily responsible for reviewing referrals for medical

services to determine medical necessity and course of action, by using their independent

judgement and extensive knowledge of medicine, along with clinical guidelines. The UM Prior Authorization Nurse confers with Nursing Manager, VP of Clinical Policy and/or Medical Director whenever appropriate in utilization management or problem solving.

Essential Duties

Reviews prior authorization referrals for medical necessity by:

• Exercising independent judgement and extensive knowledge of medicine.
• Independently reviewing and assessing records provided and determining how the patient specifically meets criteria for services being requested.
• Ensuring all health plans, state and clinical guidelines are enforced in making decisions.
• Approval Recommendations
• Developing clinical summary for why a patient specifically meets criteria for services requested.
• Independently making decision to approve services requested
• Denial Recommendations
• Developing clinical summary for why information provided does not show patient meeting criteria for services requested.
• Making recommendations for Medical Director’s review based on assessment of why information provided does not support patient meeting criteria for services requested

Qualifications/Experience

• Current CA State licensure as an Licensed Vocation Nurse (LVN)
• At least 2 years of experience in a comparable position.
• Prior authorization or Managed Care experience preferred.