Job Duties:

• The Prior Authorization Nurse is responsible for developing, implementing and maintaining general and specialized authorization processes.
• Responsible for utilization trending and making recommendations to improve utilization patterns.
• This position is also responsible for recommending contracting strategies and reporting financial savings impact to the Client.
• Provide support to the Medical Management staff, by providing information from data bases, producing reports and supporting Case Managers.
• Develop, implement and maintain authorization and referral processes.
• Create, implement and maintain workflow documentation to support authorization processes.
• Negotiate and prepares letters of agreement for out of plan services when there is no available in plan alternative.
• Monitor financial impact trending of utilization patterns.
• Produce and distribute report as needed to key stakeholders.
• Reviews all referrals and authorizations in accordance with PHP referral/authorization processing standards.
• Coordinate health care services with appropriate physician(s), facility(ies) and ancillary provider(s).
• Coordinates out-of-network and out-of-area cases with health plans, physicians, members and facilities.
• Provides support to case management staff. Identify and refer members to case management staff.
• Acts as department resource and lead by providing direction with processes, training, auditing and educating staff, and referring inquiries as appropriate.
• Gathers data and information for follow-up awhile adhering to confidentiality guidelines.
• Prioritizes and reports any concerns, improvements and possible quality issues.