Prospective Review (Prior Authorization) Clinical Nurse
Steward Health Choice is dedicated to improving the health and well-being of the people and communities we serve.
Steward Health Choice believes in a personal approach to health care right in your community. We built our health care plan around you. Our goal is to give you quality health care, programs, and services to support you on your path to wellness.
Steward Health Choice provides exceptional customer service and culturally competent care through:
- Compassionate and responsive member services team
- Collaboration with community physicians to help members get the health care they need.
- Providing culturally competent health care, including extensive translation and interpretation services
- Health programs to help members and their families stay healthy
Position Purpose: Under the direction of the Utilization Management (UM) Manager/Director and/or Medical Director ensures prospective review/prior authorization requests are completed in a timely fashion to meet contractual requirements and ensures 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, Prior Authorization and department Directors in preparation for audits and other regulatory activities.
Essential Duties and Primary Accountabilities: Listing of the major functions of the role including percentage of time allocated to each function. Should include all duties required to complete the job.
- Ensures prior authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements and ensures all reviews are conducted using nationally recognized and evidence based standards, with duties including but not limited to:
- Coordinates and follows the established preauthorization review process for outpatient services
- Produces volume of work to meet position requirements
- Evaluates clinical documentation when determining benefit coverage including appropriateness and level of care
- Reviews prior authorization requests with Medical Directors as directed
- Clearly defines and documents review rationale to support Notice of Action document
- Assists Member Services, Claims, and Provider Services department staff with issues that require clinical interpretation or explanation
- Communicates with providers or agencies as needed; documents processes accurately, thoroughly, and timely in the care management system
- Participates in Quality Improvement Projects as directed
- Performs audits of case files and staff work as directed
- Assists the Manager, Director, and others in preparation for audits and other regulatory activities
Education / Experience / Other Requirements:
- Bachelor’s degree preferred
- Arizona nursing license – unrestricted
Work Related Experience:
- Strong, clinical experience; critical thinking skills
- 1-2 years managed care experience preferred
- Prospective review experience preferred; knowledge of utilization management principles
- Skills in navigating software programs
- Position must be located in Arizona
- Computer skills required
- Ability to communicate clearly with employees at all organizational levels and across differing cultural backgrounds
Job Status: Full Time
Job Reference #: 9905