Prior Authorization Nurse / Registered Nurse 8/9/2016

Centene Corporation North Charleston, SC

Company
Centene Corporation
Job Classification
Full Time
Company Ref #
28653579
AJE Ref #
575828060
Location
North Charleston, SC
Job Type
Regular

JOB DESCRIPTION

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JOB DETAILS:

JOB TITLE : PRIOR AUTHORISATION NURSE

LOCATION : 4969 CENTRE POINTE DR. NORTH CHARLESTON, SOUTH CAROLINA 29418

DURATION : PERMANENT

ROLE AND RESPONSIBILITIES:

* Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
* Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
* Complete medical necessity and level of care reviews for requested services using CLINICAL JUDGMENT and refer to Medical Directors for review depending on case findings
* Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
* Educate providers on utilization and medical management processes
* PROVIDE CLINICAL KNOWLEDGE AND ACT AS A CLINICAL RESOURCE TO NON-CLINICAL TEAM STAFF
* Enter and maintain pertinent clinical information in various medical management systems
* Interact with providers to educate and direct care to participating network providers
* Participate in utilization management committees and work on special projects related to utilization management as needed

REQUIRED SKILLS/EXPERIENCE:

* 2+ YEARS OF CLINICAL NURSING EXPERIENCE IN AN acute care setting
* 1+ years of utilization management experience in a managed care setting
* Knowledge of utilization management principles and healthcare managed care
* Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs
* South Carolina RN license
* ASSOCIATE'S DEGREE IN NURSING (BACHELOR'S DEGREE IN NURSING PREFERRED)