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   Current UPMC employees must apply in HR Direct

Authorization Nurse

Description

Are you interested in working at Magnet-designated UPMC Magee-Womens Hospital? Only 7% of hospitals nationwide have achieved Magnet designation… and we’re one of them! For more than a century, UPMC Magee has been caring for women through all stages of their lives, and we are looking for the next talented employee to join our team.  

UPMC Magee-Womens Hospital is seeking a Full-time Authorization Nurse to support the Outpatient Oncology department!

This position will work Monday through Friday daylight shifts. Hours are subject to change based on business needs.

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. Drawing on a knowledge base of acute care experience and knowledge of payer regulations is responsible for assessing the medical necessity and ensuring the presence of supporting documentation to obtain authorization. Communicates pertinent clinical information to Physicians, Medical Directors, or CFO.

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 the 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 areas 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 licensed in the State of Pennsylvania.
  • BSN or Bachelor’s degree preferred.
  • 5 years of acute care clinical experience, 2 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 and knowledge of payer reimbursement preferred.
  • 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:

  • Cardiopulmonary Resuscitation (CPR)
  • Registered Nurse (RN)
  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

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

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   Current UPMC employees must apply in HR Direct