As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The purpose of the Prior Authorization (PA) Nurse is to provide patients, physicians and health team member services related to the appropriate utilization of the organizations resources. This position will identify, screen, coordinate and process referral determinations of requested services. By utilizing the appropriate review criteria, policies and guidelines the PA nurse promotes quality and cost effective medical care and ensure the member is receiving the appropriate care in the appropriate setting.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Responsible for providing timely referral determination by accurate:
  • Usage of the Milliman Care Guidelines
  • Identification of referrals to the medical director for review
  • Appropriate letter language and coding (denials, deferrals, modifications)
  • Appropriate selection of the preferred and contracted providers
  • Proper identification of eligibility and health plan benefits
  • Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
• Responsible for maintaining compliance in turnaround time requirements as mandated by the ICE TAT Standards
• Responsible for working closely with manager to address issues and delays that can cause a failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and plan Medical Director to facilitate quality service to the member and provider.
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management).
• Attend all mandatory meetings and training.
• Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
• Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
• All other job related duties as it relates to the job function or as delegated by the management team.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Three (3) to Five (5) years of acute care experience.
• Two years of managed care experience in Medical Management preferred.
• ICD-9 and CPT coding experience preferred.
• Experience in EZ-CAP preferred.
• Ability to communicate effectively both verbally and in writing.
• Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• Minimum Education: LVN
• Preferred Education: BA or BS in Nursing
• Minimum Experience: 3 to 5 years of acute care experience
• 2 Years Health Plan Utilization Review or equivalent work
• Preferred Experience: 5 years Health Plan Utilization Review and 5 years Acute Care
• Experience with 1 year ICU / ER

REQUIRED CERTIFICATIONS/LICENSURE

Include minimum certification required to perform the job.

• Licensure must be current and unrestricted in the appropriate jurisdiction

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to work in sitting position, use computer and answer telephone
• Ability to travel
• Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office Work Environment

TRAVEL

• Approximately 5% travel may be required

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.