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Prior Authorization Temp Nurse Case Manager, RN
Northridge, CA
4-Month Contract Assignment

• Quick On-Boarding/Placement Process
• Career Stepping Stone from Bedside Nursing to Case Management (acute care experience and working knowledge of pre-auth process required)

Description
The role of the Prior Authorization Nurse Case Manager (PACM) is topromote the quality and cost effectiveness of medical care by applyingclinical acumen and the appropriate application of policies andguidelines to prior authorization specialty referral requests.The PACMwill review for appropriate care and setting, and followingguidelines/policies, will approve services when indicated.If notindicated, PACM will forward requests to the appropriate physician ormedical director with recommendations for other determinations, ensuringthat the member is receiving the appropriate quality care in apreferred setting, while making sure regulatory guidelines are followed.
1. Understand, promote and review with the principles of medicalmanagement to facilitate the right care at the right time in the rightsetting.
2. Communicate effectively and interact with providers, staff and healthplans daily regarding medical management and referralauthorization issues.
3. Maintain a working relationship with PACM colleagues, the pre-authcoordinator team, high-risk nurse case managers, inpatient nurse casemanagers, medical directors, and network management.
4. Research alternative care plans and when necessary, assist in therouting of members to the most appropriate care/setting, in order toprovide right care/right setting.
5. When necessary, act as liaison between the case managers, UMcoordinators, contracted providers (PCPs/specialists/ancillary), and themembers/families.
6. Perform case reviews base on key screening outpatient indicators, andevaluate the PCP submitted plan of care for its completeness ofdocumentation, consistency of treatment with medical groups clinicalpractice guidelines, adherence to standard evidence-based or consensusguidelines, and health plan and CMS guidelines and/or medical policies.
7. Maintain regulatory Turnaround Time Standards per regulatory guidelines.
8. Document accurately and completely all necessary information in authorization notes.
9. Understand all applicable capitation contracts and how they apply to review duties.
10. For those PACMs involved in DME, understand the contracts, and needto review rental vs. purchase approvals, and continued use so thatequipment is picked up when needed.
11. When appropriate, coordinate and review for medical necessity andappropriate utilization any ancillary professional services, i.e. (homehealth, infusion, PT, OT, ST, etc.).
12. Demonstrates the ability to follow through with requests, sharing ofcritical information, and getting back to individuals in a timelymanner.
13. Participates in "service recovery" through follow-up with an upsetpatient or provider, gathering information, and demonstrating empathy.
14.Identifies network needs and report to management for potential contracting opportunities.
Qualifications
1.Graduate from an accredited Registered Nursing Program
2.Current California RN License
3.Minimum of 1 year acute experience
4.Knowledge of Managed Care preferred.
5.Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.
6.Knowledgeable with the pre-authorization process and workflow, with prior authorization experience preferred.
7.Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
8.Ability to deal with responsibility with confidential matters
9.Ability to work in a multi-tasking, fast-paced, high-stress environment.
Compensation
$38-$42/Hr
Negotiable based on experience