Prior Authorization Nurse

Description

JOB SUMMARY: 

The purpose of the Prior Authorization nurse is to provide timely review of authorization requests and ensure the requests meet national standards and contractual requirements. The prior authorization nurse will promote the quality and cost effectiveness of patient care using clinical acumen. As a prior authorization nurse, you review requests for authorization for specific medications, treatments, or surgeries. Duties include reviewing medical records and documents related to the application. You consider each prior authorization request and collect evidence and patient information to support your decision. You communicate with the insurance provider to obtain additional information if needed. Your responsibilities in this position also involve ensuring the authorization meets regulations and requirements and contractual obligations of all parties involved. Your job can also require coordinating with administrators and healthcare providers to gain necessary information and ensure that patients receive authorized care.

Additionally, the PA nurse will assist the clinical team with providing direct patient care services, designated independent procedures, and completing nursing tasks when needed. Provides care that meets the psychosocial, physical and general aspects of care; meets the communications needs of patient and family; provides care that reflects initiative and responsibility indicative of professional expectations, under the supervision of a registered nurse and/or physicians. Maintains regulatory requirements, nursing and office/clinic policies, procedures and standards. Communicates with physicians and team members about patient’s clinical condition, including results of diagnostic studies and symptomatology. 

JOB SPECIFIC COMPETENCIES:

• Provide timely review of authorization requests and ensure the requests meet national standards and contractual requirements.
• Provide direct patient care under the supervision of a physician PA, or NP evaluates outcomes, consults with other health team members as required and adjusts nursing care process as indicated to ensure optimal patient care.
• Ability to perform a head-to-toe assessment, under the supervision of a physician, PA or NP on all patients as per policy. This includes neonate, pediatric, adolescent and geriatric patients and the general patient population.
• Ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management.
• Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
• Performs patients care responsibilities considering needs specific to the standard of care for patient’s age.
• Demonstrates knowledge of the principles if growth and development over the life span and the skills necessary to provide age-appropriate care to the patients served. Able to interpret data about the patient’s status in order to identify each patient’s age specific needs and provide care needed by the patient group.
• Maintains current knowledge of medications and their correct administration based on age of the patient and his/her clinical condition.
• Medical and surgical asepsis is carried out during treatments and special procedures.
• Demonstrates the ability to assist physicians with procedures and perform services requiring technical and manual skills under the direction of a physician, PA and/or NP.
• Demonstrates ability to revise plan of care as indicated by the patient’s response to treatment.
• Demonstrates the ability to perform treatments and provide services to level of licensure.
• Meets current documentation standards and policies.
• Demonstrates knowledge of lab requirements, requisitions. 

Requirements

EDUCATION, CREDENTIALS & EXPERIENCE REQUIREMENTS:

• Current LPN licensure in State of Georgia
• Active American Heart Association BLS certification within 30 days of hire.
• Experience in doing prior authorizations preferred.