Prior Authorization Rn Jobs in Texas (NOW HIRING)

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General Purpose of Job:
The service coordination program supports maximizing the member's health, wellbeing, and independence. The RN will focus on person-centered care planning and will assess all the member's services and support needs, ensure timely community-based Long-Term Services and Supports (LTSS) to prevent, delay, or reduce the progression of chronic conditions and the need for institutionalization and to maintain the member safely in the community. Service coordination is a collaborative practice that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the member's health and human service's needs. It is characterized by advocacy, communication and resource management and promotes quality and cost-effective interventions and outcomes. The service coordinator facilitates clinically appropriate and fiscally responsible patient care through communication and collaboration with the physicians, Member, family, care giver, and all other members of the multidisciplinary team. The service coordination process is holistic in its coverage of the member's situation and addresses medical, physical, behavioral, emotional, financial, psychosocial, social, and other needs, as well as that as the support system. These nurses will also work with the Health Homes and primary care providers to assist with coordination of STAR Kids member's needs. The Service Coordinator RN will manage any combination of Level of Care (LOC) 1 ,2 and 3, member caseload that they are assigned. Certain medically complex members with waiver services may require the RN to be responsible for the LTSS prior authorization activities. The Service Coordinator RN will collaborate with other members of the Service Coordination team.
The Service Coordinator is responsible for the coordination and efficient utilization of health care resources for the provision of quality care for all patients throughout the continuum of care. The Service Coordinator RN: facilitates clinically appropriate and fiscally responsible patient care through communication with the providers and health plan medical directors, and all other members of the health care and health plan team, assesses and identifies the patient's clinical findings and determines, in conjunction with the Physician Advisor/Health Plan Administration, established benefits, protocols, pathways, and evidence-based medicine tools, the health care services and level of care appropriate for the member, communicates with providers of care/services to ensure appropriate levels of care and coordination of LTSS for applicable members.
Essential Duties and Responsibilities:
To perform this job successfully, an individual must be able to perforin each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by Health Plan leadership, as required.
Education and/or Experience:
This position can be filled as an RN, Nurse Practitioner, or Physician's Assistant.
• RN with Bachelor of Science in Nursing (BSN) degree from four-year college or university or Associates Degree in Science (ADNS) with combination of education and experience in managed care, STAR+Plus, children with special health care needs, or Long Term Supports and Services (LTSS) for individual enrolled in various waiver programs through the Department of Aging and Disability Services (DADS) preferred.
• Certified Case Manager (CCM) certification preferred.
• Minimum of 3 years of clinical experience as a Registered Nurse with one year of experience as a case manager or managed care case/utilization management experience preferred.
• Minimum of three (3) years prior management experience in health services within a managed care organization preferred.
• Must have an in-depth knowledge of the State of Texas' managed care and managed Medicaid process preferred.
• Previous experience with the State of Texas STAR+PLUS program or similar programs dealing with SSI and disabled children preferred.
• Knowledge of Medicare preferred.
• Resource Utilization Group (RUG) and/or Patient Driven Payment Model (PDPM) certification preferred.
Licenses, Certifications, Registrations:
• Current, active, and unrestricted RN, NP, or PA licensure in the State of Texas
• Certified Case Manager (CCM) designation preferred.
• Current Texas driver's license and insurance maintained throughout the term of employment.