Prior Authorization Nurse Specialist HFHP - Clinical Operations

Health First - Rockledge, FL

Full-time - Entry Level

Rockledge, FL

Ambulatory Health Care Services

About the position

The Prior Authorization Nurse Specialist at Health First is responsible for managing the Prior Authorization Process to ensure quality, customer experience, and stewardship. This role involves accurately processing prior authorization requests, adhering to regulatory standards, and collaborating with healthcare professionals to ensure compliance with medical necessity guidelines. The specialist will also engage with customers to address inquiries and provide professional service, while contributing to departmental performance metrics.

Responsibilities

• Accurately processes prior authorization requests in accordance with member contract provisions and medical policies.
• Maintains confidentiality and adheres to HIPAA requirements.
• Partners with professionals to ensure adherence to regulatory standards and accreditation guidelines.
• Refers cases to Medical Director when treatment requests do not meet medical necessity guidelines.
• Demonstrates knowledge of Utilization Management and Case Management standards.
• Achieves individual productivity and quality metrics set by management.
• Provides accurate and professional service to customers regarding authorization requests and benefit coverage.
• Identifies problems or complex cases for possible case management intervention.
• Utilizes Health First Health Plan resources cost-effectively and recommends alternatives in care.
• Participates in special projects to positively impact administrative costs.

Requirements

• Excellent attention to detail and quality of work product.
• Advanced computer skills, including navigation within EMR and Microsoft Office applications.
• Advanced understanding of procedural and diagnosis coding.
• Knowledge of insurance claims processing related to authorizations.
• At least 2 years experience in managed care, preferably Medicare.
• 3 years work experience in a direct patient care setting, preferably in a hospital acute care setting.
• Prior authorization experience is preferred.
• Current unrestricted Florida Licensure as an RN or LPN.

Nice-to-haves

• Experience in a fast-paced, stressful environment.
• Ability to work a flexible schedule.

Benefits

• Health insurance coverage
• Paid time off
• Retirement savings plan
• Professional development opportunities