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WellCare - Nursing Careers

Prior Authorization Review Nurse - RN Job

Full Job Title: *Prior Authorization Review Nurse - RN

Job Number: 1804872

Location: Phoenix, AZ

Date Posted: 2018-07-07

This position is for Care1st Health Plan in Phoenix, AZ, a WellCare Health Plans, Inc. company.

Department: Health Services - Medicaid

Reports to: Clinical Care Supervisor

Location: E. Camelback Rd, Phoenix AZ 85016

Job Type: Hourly/Non-exempt

Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, outpatient services and out of network providers. Reviews medical records, uses clinical expertise and compares information to established guidelines and the members benefit plan. Works closely with departmental management staff to impact the treatment plan and identify treatment plan alternatives.
  • Utilizes Well Care designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with review determinations.
  • Evaluates all requests for service, to determine the Company's financial liability including the collection of information regarding subrogation and COB and entry in the Health Services system.
  • Ensures accurate coding using CPT-4 and ICD-9 codes. Documents all information accurately.
  • Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
  • Adheres to all confidentiality requirements.
  • Applies appropriate benefits information to determine if requested services are a covered benefit.
  • Applies medical knowledge and experience to authorize pre-service requests.
  • Arranges for transfer to in-network care when appropriate.
  • Initiates process for Letter of Agreements for out of network provider requests that meet approval criteria.
  • Identifies cases appropriate for case management and makes appropriate referrals.
  • Identifies potential quality of care issues and refers to the Quality Department.
  • Meets service standards for decision turn around times and written correspondence
  • Performs special projects as assigned.

Education: Licensed Practical Nurse. A Bachelor's Degree in Health Services or nursing preferred.
Experience: 2-4 years clinical experience in an acute care facility. Managed care experience preferred. Previous experience working with treatment teams to meet the healthcare needs of participants. Knowledge of community, state and federal laws and resources.
Licenses/Certifications: Minimum of LPN licensure with current unrestricted license
Special Skills (e.g. 2nd language):
Ability to review and interpret treatment plans
Ability to define problems, collect and interpret data, establish facts, draw valid conclusions and process work to completion
Technical Skills/Requirements:
Intermediate knowledge in Microsoft Office including Word, Excel and Outlook Express
Software Proficiency: Intermediate
Verbal Communication - Able to clearly present information orally and/or influence others through oral
presentation in positive or negative circumstances.
Written Communication - Able to write effectively and to extract information from written materials.
Team Work - Able to work with people in such a manner as to build up high morale and obtain group commitments
to goals and objectives.
Organization and Planning - Able to organize or schedule people or tasks; to develop action plans leading to
specific goals; and to plan effectively.

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Last Updated On: 12/9/2015