Job Description

Job Title: Authorization Nurse
Job ID: 736930
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility:
Department: Rev Cyc Care Mgmt
Location: , Pittsburgh PA

Description

Are you looking for a unique nursing position that will utilize your experience in care management and payor relations? Do you have a working knowledge in pre-service authorizations for procedures and medicine? UPMC Corporate Services is hiring a Full-Time Authorization Nurse to support the Corporate Care Management operations, location in the South Side neighborhood in the city of Pittsburgh.

This position will work daylight hours, Monday through Friday, with eventual possibility to work from home.

Provides support to appropriate UPMC departments and health care providers by obtaining referrals and/or authorizations for any service or treatment. Drawing on a clinical knowledge base and knowledge of payor regulations, is responsible for assessing medical necessity and ensuring the presence of supporting documentation to obtain authorization. Communicates pertinent clinical information to Physicians, Medical Directors or CFO.

Responsibilities:
  • Act as a resource to other departments as well as the care managers leveraging clinical expertise relative to the authorization process.
  • Assist in determining system-wide care management needs through investigation of authorization process and identification of root cause.
  • Collaborate with other departments to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness.
  • Communicates to the Medical Directors, Attending Physicians and/or CFO, if indicated, regarding evaluation of medical appropriateness.
  • Ensure clinical review process is followed in order to meet payor deadlines.
  • Identify and assigns a root cause to each case to ensure denial reasons are tracked.
  • Maintain collaborative relationships with utilization management and departments at payor organizations.
  • Maintain current knowledge of regulatory guidelines related to authorizations.
  • Monitor and evaluates for area of process improvement related to the payor specific authorization process.
  • Perform clinical review for cases referred for cases requiring authorization or adherence to payor medical policies.
  • Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process.
  • Report to management on an ongoing basis trends/barriers that could necessitate process improvement from a concurrent standpoint.
  • Serve as a liaison between care managers and payors and facilitates payor/physician contact when indicated.

Qualifications

  • RN required
  • BSN or Bachelors degree preferred 
  • Licensed in the State of Pennsylvania. 
  • 5 years clinical experience 
  • 2 years payor or care management experience. 
  • Acute care nursing experience strongly preferred 
  • Understanding of clinical and care management process 
  • Knowledge of medical necessity criteria (InterQual). 
  • Ability to apply InterQual criteria appropriately 
  • Prior utilization review experience 
  • Knowledge of payor reimbursement structure. 
  • Excellent customer service skills. 
  • Negotiation skills for obtaining appropriate level of care. 
  • Critical thinking/assessment skills. 
  • Self motivation/autonomy. 
  • Organization/time management and prioritization skills. 
  • Proficient in Microsoft Word and Microsoft Excel. Experience working with databases preferred.


Licensure, Certifications, and Clearances:
  • Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $28.37 to $47.88

Union Position: No

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