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   Current UPMC employees must apply in HR Direct

Authorization Nurse

  • Job ID: 661966371
  • Status: Part-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: $30.17 to $50.94 / hour

Description

UPMC Corporate Revenue Cycle is hiring a regular, part-time Authorization Nurse for the Care Management department.  This part-time position works four days a week.  This position has remote work flexibility.

The Authorization nurse provides support to appropriate UPMC departments and healthcare providers by obtaining referrals and/or authorizations for any acute admissions, hospital services and treatments. The candidate will draw on a knowledge base of acute care experience and knowledge of payer regulations, is responsible for assessing medical necessity and ensuring the presences of supporting documentation to obtain authorization. They also communicate pertinent clinical information to Physicians, Medical Directors or CFO.

If this sounds like a fit for you, apply online 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 and two years payer or care management experience are required.
  • 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

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life &emdash; because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct