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- San Francisco, CA
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Remote Prior Authorizations Nurse : RN
Alvarez & Marsal Holdings, LLC. • San Francisco, CA
Posted 11 days ago
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Alvarez & Marsal -
Job Title: Remote Preauthorization RN Coordinator (CA PPO Turnaround Project)
Business Unit: Healthcare Industry Group - Clinical Support Services
Alvarez & Marsal is a leading independent global professional services firm, specializing in providing turnaround management, performance improvement and corporate advisory services, is seeking to expand its Healthcare Industry Group practice with an emphasis in clinical management through its newly formed Clinical Support Services business unit. With more than 2,600 professionals based in locations across North America, Europe, Asia, and Latin America, our firm excels in problem solving and value creation. Drawing on a strong operational heritage and hands-on-approach, our professionals work closely with organizations and stakeholders to help tackle complex business issues and maximize value.
Under the direction of the Utilization Management (UM) Manager, the Prior Authorizations Nurse-RN, acting within the scope of the Board of Registered Nurses of the State of California, ensures that prior authorizations requests are completed in a timely fashion to meet contractual regulatory requirements and ensures that all reviews are conducted using nationally recognized and evidence based standards; Participates in Quality Improvement Projects as directed; Performs audits of medical records as directed; and Assists the U M Manager as requested in preparation for audits and other regulatory activities.
Main Duties & Responsibilities:
•Assess all the requests for medical services requiring clinical review against approved evidence-based criteria.
•Communicate with patient, provider, facility, and internal work groups regarding outcome of requests
•Act as clinical resource for all work groups
•Coordinate health management services in an effort to provide integrated health services for each patient and provide benefit and health information to patients, care givers, providers and facilities to enable informed health decisions
•Clinical review of all requests for health services or treatment that require assessment against clinical criteria
•Research status of vague or questionable procedures and present to the Medical Director for review
•Identify potential high risk/high cost cases and chronic condition cases and refers to the appropriate case management team
•Identify care coordination opportunities for patients being admitted for elective surgical procedures
•Prepare letters explaining non-covered requests
•Document interventions in the database
•Direct out of network requests to in network providers to ensure members secure the optimum desired benefits and negotiate fee arrangements with out of network providers, as needed
•Facilitate the discharge planning process during pre-service review and coordinate with other clinical work teams
•Notify Medical Director of all requests you are unable to certify within designated time frames
•Provide monitoring and oversight of non-clinical staff activities and be available to non-clinical staff during business hours
•Maintain a working knowledge of all Client PPO workflows
•Strong ability to communicate effectively with patients, employer groups, and physicians
•Effective problem solving skills
•Strong Computer skills
•Possess excellent time management skills
•Licensed as a Registered Nurse in the state of California with an unencumbered license
•Minimum of five years clinical experience
•Experience in health management
•Possess the ability to make independent decisions when circumstances warrant such action, deal tactfully with personnel, residents/patients, family members, visitors, etc., and seek out new methods and principles and be willing to incorporate them into existing practices.
•Possess ability to educate, inform, advocate, promote and facilitate health care options, and demonstrate the willingness to work harmoniously with a team approach.
• Must have patience, tact, cheerful disposition and enthusiasm and be able to relate to and work with ill, disabled, elderly, emotionally upset residents/patients and their families.
•Must be able to read, write and speak the English language.
•Must be able to use a computer for data entry and to send and retrieve webmail.
Reports To: UM Manager
Supervisory Responsibilities: None
It is A&M’s policy to provide equal employment opportunity to all employees and applicants for employment without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit based factor in accordance with all applicable laws, directives and regulations of federal, state and city entities.