Prior Authorization LVN

Our client has an opening for Prior Authorization LVN to support a contract role in Austin, TX.

REQUIREMENTS:

- Must meet Texas State Registered Nurse licensure requirements and possess current and unrestricted Registered Nurse license from the State of Texas.
- Proficient analysis and problem solving capabilities.
- Proficient critical clinical thinking skills.
- Must be able to communicate in English (verbal/written).
- Minimum of two (2) years post licensure clinical nursing experience.
- Basic computer knowledge with the ability to learn additional computer programs, required.
- Excellent interpersonal and communication skills.
- Demonstrated ability to effectively and sensitively interact with people from different cultural groups.
- Prior Authorization experience.
- Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits, preferred.
- Bachelor of Science Nursing (BSN) degree (preferred) from an approved/accredited school of nursing; at a minimum: Associates Degree or Diploma required.

RESPONSIBILITIES:

- Utilizes client specific criteria sets (eg, Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
- Conducts pre-service, concurrent/continued stay, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Conducts any utilization or medical management review activities which require the review of clinical information against client specific criteria as noted above, but excludes denial determinations.
- Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
- Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
- Collaborates with providers to assess members, needs for early identification of and proactive planning for discharge planning.
- Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required.
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
- Collaborates with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of psychosocial care for members with mild to moderate, acute or chronic psychiatric and/or behavioral health needs and appropriateness of treatment setting within the scope of professional limitations by utilizing the applicable rules of the Texas Administrative Code (TAC), Texas Health and Human Services Commission (HHSC) approved medical policy, and industry standards.
- Accurately interprets benefits and managed care products, and may steer members to appropriate providers, programs or community resources.
- Works with medical directors in interpreting appropriateness of care.
- Maintains standards of professional and ethical practices in the provision of the full scope of social work intervention.
- Provides case management responsibilities as needed.