Works as part of integrated team and is involved in reviews of authorization requests and communicates with the physicians and clinic when additional information is needed or assists clinical practitioner's office in re-directing care to an appropriate plan provider or facility. Performs activities that include obtaining payer authorization for outpatient services that require notification/authorization based on payer specific guidelines. Responsible for clinical part of audit to determine if all charges have been captured appropriately. Maintains a thorough understanding of the plan's provider contracts, authorization requirements and Interqual Criteria Provides ongoing follow-up and re-evaluation of clinical departments/areas as requested or needed for authorization review. Performs prior authorization and retrospective clinical review according to Interqual Criteria', Medicare Guidelines and established payer protocols to determine the medical appropriateness of ordered pre and post scheduled services. Enters authorization information into EPIC and maintains authorization data.
Education/Specialized Training/Licensure: Nurse in good standing, currently licensed in the State of Texas without stipulations in practice as an Licensed Vocational Nurse
Work Experience: Minimum 3 years of hospital experience in various clinical areas (required). 1 year utilization review, authorization or case management experience (preferred). Familiarity with hospital coding and billing processes (preferred). Knowledge of Interqual/Milliman guidelines (preferred). EPIC EMR experience (preferred).
Management Experience: Preferred but not necessary.
Equipment Operated: PC functions, calculator, general office equipment
Above Average Verbal (Heavy Public Contact)
Exceptional Verbal (e.g., Public Speaking)
Writing /Composing (Correspondence/Reports)
Other Skills: Analytical, Mathematics, Medical Terms, P.C.
Work Schedule: Flexible
Other Requirements: Requires travel to Harris Health System facilities. Must be able to interact successfully in a culturally diverse environment.