Prior Authorization Nurse

WHO WE ARE:

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

WHO YOU ARE:

This position performs utilization management review. This position determines appropriateness of services, medical necessity, and location of services required to encourage effective, high-quality care and cost-efficient outcomes through. This position requires excellent verbal and written communication, organization and time management skills.

ESSENTIAL JOB FUNCTIONS:

• Reviews preservice requests, appropriateness of services, and ensure timely determination
• Communicates with customers, both internal and external, regarding status of referral/referral process.
• Utilizes NCDs, LCDs, MCG, and additional guidelines to assist in determining coverage of the request.
• Maintains current knowledge of managed care issues (benefits, contracted providers, health plan guidelines, MCG, NCD, LCD and community standards of practice and regulatory developments, and new and experimental procedures).
• Collaboration with internal team to support member needs, including but not limited to discharge planning, provider relations, and care management.
• Adheres to company and department policies and procedures.
• Performs other duties as assigned

EDUCATION AND EXPERIENCE:

• Current active LPN license in Oklahoma/Texas or compact
• Experience in managed care/utilization management preferred
• Minimum of 3-5 years of clinical experience required

KNOWLEDGE, SKILLS AND ABILITIES:

• Working knowledge of ICD-10/CPT codes preferred
• Working knowledge of Microsoft software programs
• Excellent organizational skills
• Strong communication skills
• Proven ability to work independently and as a member of a team

WORK ENVIRONMENT:

Current work environment is remote; however, some state exclusions apply.

Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.

TRAVEL:

May require limited travel for offsite meetings or training

SUPERVISORY RESPONSIBILITY:

This position has no supervisory responsibility

OTHER DUTIES:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.