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Prior Authorization/Utilization Review Nurse

    • Job Tracking ID: 512689-593295
    • Job Location: Milwaukee, WI
    • Job Level: Mid Career (2+ years)
    • Level of Education: BA/BS
    • Job Type: Full-Time/Regular
    • Date Updated: October 27, 2017
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
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Job Description:

This professional position reviews the clinical appropriateness of prior authorization (PA) requests and ensures that all benefits authorized meet medical necessity and other Medicare and/or Medicaid criteria if applicable to promote cost-effective delivery of health care services.  Works with the Chief Medical Officer (CMO)/Medical Director to review PA requests, and ensures appropriate information sharing takes place between the PA Department and Care Management and/or other Departments to facilitate proper care management activities. 

  1. Review PA requests for home health services, durable medical equipment, outpatient therapies, skilled nursing facility therapies, and all outpatient procedures pursuant to applicable Medicare and Medicaid criteria, iCare guidelines, and PA Department policies and procedures.

  2. Provide complete and accurate documentation specifying the rational for approval, or for forwarding to the CMO/Medical Director for further review.

  3. Create reduction/denial letters based on the CMO/Medical Director’s review and applicable guidelines.

  4. Maintain a thorough understanding of Medicare and Medicaid guidelines and stay abreast of updates and changes.

  5. Work in collaboration with the PA staff to ensure timely and efficient completion of all workflows within the Department.

  6. Fully participate in iCare’s Compliance Program, including compliance with iCare’s Code of Conduct, policies and procedures, and all applicable Privacy and Security laws.

Experience and Skills:

  1. Licensed as a Registered Nurse in the State of Wisconsin with at least two years of experience in clinical care in long term and rehabilitation care settings, related health care experience in a hospital or other clinical care setting, or previous prior authorization experience.

  2. Advanced clinical literacy and judgment in the residential care of individuals with a nursing home level of need.

  3. Ability to secure the cooperation and compliance of key nursing home leadership in requests for information and documentation.

  4. Ability to communicate and enforce best practice standards in the care of iCare members with nursing home levels of need.

  5. Strong analytical skills in tracking and reporting utilization, practice patterns, and significant deviations.

  6. Ability to determine appropriateness of member’s care.

  7. Demonstrated flexibility, ability to effectively set priorities between daily demands and long-term work assignments and projects while consistently meeting deadlines and demonstrating accuracy in documentation.

  8. Experience in health care cost containment through innovative utilization review practices.

  9. Proficiency in effective communication of thoughts, ideas, and information both orally and in writing.

  10. Ability to use a personal computer and ability to quickly learn software applications necessary for the work of the position.

  11. A personal vehicle, valid State of Wisconsin motor vehicle operator’s license and conformity with insurance coverage limits are required.

  12. Must be able to travel to any location within iCare service area.


 

 
 
 
  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
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