| Responsibilities Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards | ||||||
| Story Behind the Need | ||||||
| This team will be responsible for redirecting Out of Network authorizations to In Network providers. Driving the request: There is an anticipated large volume of requests that will need to be redirected as a Northwell Health Network that may be non-renewed. | ||||||
| Typical Day in the Role | ||||||
| Hired Candidates will be working from a queue of received authorizations. The cases may be received via Outlook or FileNet. The candidate will document in Facets. They will be required to make outreach to providers and members, generate letters. The candidate will be conducting Medical Necessity reviews The performance metrics is approximately 1.5-2.4 cases/hour. Provider and member outreach Applications Centene facets, filenet, Phone system, fedelis portal Applications Microsoft Teams, Outlook, web browser, excel, word, one drive | |||||
| Candidate Requirements | ||||||
| Required: Requires Graduate from an Accredited School of Nursing OR Bachelor s degree in Nursing AND 2 4 years of related experience. | Preferred: | |||||
| Required: LPN or RN | Preferred: RN | |||||
| Years of experience required: 2-4 years of Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience, familiar with MCG or Interqual, phone etiquette Disqualifiers: Not having a professional environment to work remotely, not having reliable internet (please use hotspot or get to a secure place with wifi to continue working) Additional qualities to look for: Prior Facets experience, knowledge of clinical terminology, prior office or insurance experience, familiar with MCG or Interqual | ||||||
| 1 | Tech savvy, ability to work in multitask in multiple systems at once while speaking | ||||
| 2 | Strong communication skills, written and verbal, phone etiquette | |||||
| 3 | Clinical documentation A MUST | |||||
| Candidate Review & Selection | ||||||
| Projected Manager Candidate Review Date: | 24-48 hours | ||||
Type of Interviews: | Teams CAMERA ON (Please be ready to interview/ ATTIRE AND LOCATION) | |||||
| Required Testing or Assessment (by Vendor): | ||||||
| Next Steps | ||||||