Remote Prior Authorization Nurse Jobs in Raleigh, NC

The Administrative Clinical Support Specialist I performs a range of administrative tasks, resolves problems and may coordinate administrative support activities that require knowledge of program operations, policies, and processes.  The position will be responsible for the transferring of clinical data, conducting pre-review screening of prior authorization requests, completing discharge documentation, and ensuring administrative supports are in place to meet required departmental deadlines in accordance with contractual, federal and accreditation standards.

This position is fulltime remote. Selected candidate must reside in North Carolina. While there is no expectation of being in the office routinely, they may be required to report to the Alliance Home Office (Morrisville, North Carolina) for business meetings as needed.

Responsibilities & Duties

Program Operations

• Triage, process, and gather clinical information to build prior authorization requests that are received via email/fax into our electronic health record platform
• Support the UM department in ensuring notification to members and providers occur within required time frames
• Adhere to all HIPAA and organizational privacy and security policies to ensure confidentiality, integrity and protection of patient health information (PHI)
• Utilize NC TRACKs to accurately verify member eligibility in support of clinical and administrative workflows
• Other functions include support for high priority, time sensitive and daily procedural tasks such as pre-screening prior authorization requests, completing discharge documentation, responding and supporting providers and, related non-clinical activities according to policies, procedures and regulatory compliance guidelines

Administrative Support Activities

• Complete data entry (intake function) for prior authorization requests submitted by means other than electronic provider portal (E.g., Email, fax, phone)
• Transfer of clinical information to facilitate Peer Review of prior authorization requests via the delegated vendor portal
• Gather of clinical information to facilitate peer-to-peer review and re-review processes
• Respond to providers inquiries related to the status of a prior authorization request and UM operational procedures. Response time must be consistent with contractual and accreditation standards detailed in Policy and Procedures
• Reference and adherence to all applicable agency policies, operational procedures, desk procedures, and best practices to ensure compliance with regulatory requirements and contractual obligations through the accurate execution of job responsibilities

Minimum Requirements

Education & Experience

Required:

High School diploma and four (4) years of related administrative experience to include a minimum of two (2) years performing administrative support functions, preferably within a clinical, health information, or healthcare administrative setting.

Knowledge, Skills, & Abilities

• Demonstrates consistent compliance in handling, accessing, transmitting, and storing sensitive clinical data and reports potential privacy or security concerns in accordance with established procedures
• Demonstrate strong technical aptitude and efficiencies in navigating multiple platforms/portals to support daily operations
• Knowledge of office management, including the ability to organize workflow and coordinate activities among department staff
• Ability to do calculation, summarize, compile and tabulate numerical material
• Ability to maintain work standards of programs activities and ability to analyze and correct errors
• Ability to maintain an effective working relationship with other employees and the public
• Proficiency with databases and the ability to navigate through SharePoint
• Knowledge of NC Tracks & Alliance Medical Records electronic system
• Ability to collaborate with multi-departmental and multi-unit teams
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required

Salary Range 

$20.73-$26.43/ Hourly 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity 

 An excellent fringe benefit package accompanies the salary, which includes:   

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility