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The role of the Prior Authorization Nurse Case Manager (PACM) is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests. The PACM will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated. If not indicated, PACM 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.

Responsibilities

• Understand, promote and review with appropriate medical management to facilitate the right care at the right time in the right setting.
• Communicate effectively and interact with providers, staff and health plans daily regarding medical management and referral authorization issues.
• Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management.
• Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
• When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
• Perform case reviews based on key screening outpatient indicators, and evaluate the PCP submitted plan of care for completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies.
• Maintain regulatory Turnaround Time Standards per regulatory guidelines.
• Document accurately and completely all necessary information in authorization notes.
• Understand all applicable capitation contracts and how they apply to review duties.
• For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed.
• When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
• Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
• Participates in "service recovery" through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
• Identifies network needs and reports to management for potential contracting opportunities.

Qualifications

• Graduated from an accredited Registered Nursing Program
• Current California RN License
• Minimum of 1 year acute experience
• Knowledge of Managed Care preferred.
• Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.
• Knowledgeable with the pre-authorization process and workflow, with prior authorization experience preferred.
• Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
• Ability to deal with responsibility of confidential matters
• Ability to work in a multi-tasking, fast-paced, high-stress environment.

Compensation

$38-$42/Hr Negotiable based on experience

Care Navigators On Demand is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.