Job Description

Job Title: Authorization Nurse PA/NY
Job ID: 44121951
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility:
Department: Rev Cyc Care Mgmt
Location: 2 Hot Metal Street, Pittsburgh PA 15203

Description

Purpose:
Join the Corporate Revenue Cycle Team as an Authorization Nurse!  This role 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, this position is responsible for assessing medical necessity and ensuring the presence of supporting documentation to obtain authorization. The Authorization Nurse communicates pertinent clinical information to Physicians, Medical Directors or CFO.

This position is based in Pittsburgh at the Quantum building.  The schedule is Monday through Friday during normal business hours.  This is a Work from home position after satisfactory completion of onsite orientation. Rotating weekends and holidays are required. This position also requires eventual licensure in the state of New York after 30 days of hire.

Responsibilities:
  • Serve as a liaison between care managers and payors and facilitates payor/physician contact when indicated.
  • Communicates to the Medical Directors, Attending Physicians and/or CFO, if indicated, regarding evaluation of medical appropriateness.
  • Act as a resource to other departments as well as the care managers leveraging clinical expertise relative to the authorization process.
  • Collaborate with other departments to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness.
  • Ensure clinical review process is followed in order to meet payor deadlines.
  • Report to management on an ongoing basis trends/barriers that could necessitate process improvement from a concurrent standpoint.
  • Assist in determining system-wide care management needs through investigation of authorization process and identification of root cause.
  • Identify and assigns a root cause to each case to ensure denial reasons are tracked.
  • Monitor and evaluates for area of process improvement related to the payor specific authorization process.
  • Maintain current knowledge of regulatory guidelines related to authorizations.
  • Perform clinical review for cases referred for cases requiring authorization or adherence to payor medical policies.
  • Maintain collaborative relationships with utilization management and departments at payor organizations.
  • Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process.
  • Effectively communicates pertinent clinical information to the payor in order to obtain authorization for inpatient services.
  • Monitors the collection, copying and transmittal of pertinent clinical information required to obtain insurance authorization.
  • Provides prompt payor feedback to Care Managers/Social Workers enabling them to re-evaluate/re-direct the current patient plan of care in order to streamline the delivers of services.
  • Serves as a liaison between the floor Care Managers and Payors and facilitates payor/physician contact when indicated.
  • Maintains patient certification information, enters certification data in appropriate systems and communicates certification status to floor Care Managers/insurance verification, transplant credit, etc.
  • Maintains the denial management processes for concurrent denials/appeals, tracking and reporting denial information.
  • Performs medical record review as needed to provide necessary clinical information to payor.
  • Serves as a resource on payor requirements for Severity of Illness (SI) and Intensity of Service (IS) determinations including observation and inpatient status.

Qualifications

  • RN required; BSN or Bachelors degree preferred. 
  • Licensed in the State of Pennsylvania and State of New York. 
  • Five years of acute care clinical experience, two years payer or care management experience. 
  • 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 payer 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 New York License required within 30 days of hire

  • Registered Nurse (RN)

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

    Salary Range: $29.22 to $49.32 / hour

    Union Position: No

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