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Authorization Nurse

  • Job ID: 412074499
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: Corporate Revenue Cycle
  • Department: Rev Cyc Care Mgmt
  • Location: 2 Hot Metal Street, Pittsburgh PA 15203
  • Union Position: No
  • Salary Range: $26.16 to $43.49 / hour

Description

UPMC Corporate Revenue Cycle is hiring an Authorization Nurse to join our team! This position will work Monday through Friday as well as rotating weekends. The Authorization Nurse will be a remote position.

In this role you will be responsible for ensuring that authorization forms are approved for scheduled surgeries or patient admissions. The role provides support to appropriate UPMC departments and healthcare providers by obtaining referrals and/or authorizations for any acute admissions, hospital services and treatments. The position draws on a knowledge base of acute care experience and knowledge of payer regulations and is responsible for assessing medical necessity as well as ensuring the presences of supporting documentation to obtain authorization.

If you are someone who enjoys nursing, then this is the next step for you! Apply today.

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.

Qualifications

  • RN required; BSN or Bachelors degree preferred. 
  • Licensed in the State of Pennsylvania. 
  • 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 (RN)

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

    Total Rewards

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       Current UPMC employees must apply in HR Direct

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