A Prior Authorization Nurse provides a timely review of authorisation requests and ensures the requests meet the national standard and contractual requirements. Daily responsibilities are often listed on the Prior Authorization Nurse Resume as – performing clinical reviews of authorisation requests using appropriate criteria, providing accurate and complete documentation with the rationale used to approve requests, collaborating with staff within provider networks and case management team coordinate patient care, equipping and training prior authorisation tech with needed resources, and maintaining clinical information in multiple health management systems.
Skills and abilities often considered crucial for completing the job include – knowledge of utilisation management and case management principles; knowledge of MS Word, strong service orientation and professionalism, and a driver to work well with a team. A bachelor’s degree in nursing and state licensure as a Registered Nurse is vital for this role.
Headline : Prior Authorization Nurse is Providing medical care to individuals who are not eligible for admission or treatment at the facility where they reside or that they are admitted. This may include minors, patients with disabilities, and other individuals who do not require hospitalisation or medical assistance, responsible for making sure the patient demonstrates a true need for medical care and treating accordingly.
Skills : ICD-9 and ICD-10 CPT coding, Knowledge/experience Interqual.
Description :
Responsible for reviewing authorization requests against InterQual criteria, CMS guidelines and Peoples Health policies.
Responsible for data entry of requests and additional documentation tracking of requests in CCMS and Macess.
Responsible for complete and accurate documentation of medical necessity for services.
Initiated Care Coordination (Nurse Practitioners, MSW and RN) referrals for members when necessary .Enters authorisation data into CCMS for Home Health and Outpatient Wound Care requests.
Communicated with Medical Management Manager and Medical management Supervisor on a regular basis reviewing outstanding authorization requests.
Assisted in the resolution of issues/problems to provide the member with adequate care.
Coordinated and cooperated with Health Services staff regarding inquiries and entry of requests into CCMS.
Experience
5-7 Years
Level
Executive
Education
Diploma
Prior Authorization Nurse Resume
Objective : To obtain a Prior Authorization Nurse position, which will allow me the opportunity to utilize my training, skills, and education, with the potential for upward mobility and to make a difference in the health of patients by providing quality care.
Skills : ACLS, BLS, CPR, And IV Certification.
Description :
Responsible for reviewing prior authorisation requests for medical procedures by using clinical documentation from various providers to evaluate for medical necessity based upon Medicare guidelines, Interqual Criteria, and nursing knowledge.
Processed requests within the time frame allotted as per Centers for Medicare and Medicaid Services (CMS) guidelines.
Conveyed and recorded authorizations within the notes using EZ-Cap database, creating and issuing denial letters as appropriate and reviewing grievance and appeals cases for medical necessity.
Referred cases to medical director for further review when request did not meet medical necessity guidelines or initiate peer review to establish if request is appropriate for members needs.
Coordinated members care with other team members within prior authorization department and outside of department.
Communicated by phone with providers and members when additional information was needed to process requests or to give notification of decision regarding request.
Assisted care coordination with authorisations for home health and durable medical equipment to assist with safe discharge.
Experience
2-5 Years
Level
Executive
Education
GED
Prior Authorization Nurse Resume
Headline : To achieve high Prior Authorization Nurse professional and personal goals by utilising my excellent management, marketing, sales, customer service, organizational and problem-solving skills. Utilizing clinical background and knowledge would be a plus.
Skills : Windows, Word, Internet, Cash Handling, Cash Register, Tour Guide, Excel.
Description :
Completed prior authorizations for MDwise Select Health, Healthy Indiana Plan Applied Interqual criteria to determine if requests meet medical necessity.
Worked closely with the medical director and sent medical reviews for approval/denial.
Found solutions for payment by working with MDwise in relation to rejected claims.
Established rapport with health care providers' office staff to provide the best care for clients.
Am well versed in MDwise policies, procedures, and IAC.
Provided support to case managers regarding their members' authorizations and questions pertaining to the authorization process.
Worked with CPT coding and ICD-9 in regards to claims.
Experience
5-7 Years
Level
Executive
Education
Diploma
Prior Authorization Nurse Resume
Summary : As a Prior Authorization Nurse is responsible for Providing care and safeguard patients from harm, neglect, and abuse in a safe environment, Ensuring the safe delivery of medically necessary services to patients, Documenting care and treatment, including all medications, vaccinations, procedures, and other health care services provided.
Skills : Planning, Document Care, Critical Care.
Description :
Performed pre-authorisation for surgical procedures, diagnostic tests, durable medical equipment, rehabilitation, home care services, and infusion therapy.
Negotiated contracts for provider network participation and pricing.
Supervised coordinators; Presented information to staff, providers and members regarding cases, payments, and procedures according to the Fund's guidelines.
Recorded and trouble shoot members' inquiries and concerns.
Created and updated policies and procedures.
Developed the Disease Management Program for pregnancy, diabetes, asthma and cardiac services.
Performed prior authorisation reviews according to Interqual Criteria, Medicaid Guidelines and established protocols to determine the medical appropriateness of requested treatment.
Experience
10+ Years
Level
Senior
Education
Business Administration
Prior Authorization Nurse Resume
Headline : To provide the highest quality patient care as a licensed vocational nurse and contribute to a professional medical organisation while improving my patient's well-being. Current CPR - BLS certification, PEARS certification, State hearing/vision screening certifications Knowledge of Next Gen EMR/EPM, Microsoft Office programs.
Skills : Proficient In Microsoft Excel ,word,power Point, Fully Bilingual English/Spanish, Excellent Organisational And Communication, Exceptional Knowledge Of U.R, Case Management And Prior Authorisation.
Description :
Reviewed medical documentation for Medicare HMO members for certain testing, procedures, and surgeries that are requested by their physicians.
Researched is necessary, using Interqual and CMS Medicare guidelines as well as nursing judgement in order to make a final approval.
Coded must be listed on the requests in order to make sure the procedures are appropriate for the member.
Performed prior authorization and retrospective review according to Medicare Guidelines and established protocols to determine the medical appropriateness of medications.
Adhered to the HIPAA and Privacy Standards and Confidentiality Agreement.
Communicated with members of the treatment team, reviews medical records, uses clinical expertise and compares information to established guidelines and the member's benefit plan.
Maintained a thorough understanding of the Plan's provider contracts, authorisation requirements.
Experience
5-7 Years
Level
Executive
Education
BS In Health Related
Prior Authorization Nurse Resume
Headline : Prior Authorization Nurse with the knowledge and ability to apply various care guidelines while working with physician advisor's to complete reviews within set time frames. Able to work in a fast paced environment to meet the needs of clients, Utilisation Review Case Management Prior Authorisation Interqual Guidelines Concurrent ReviewMCG 20TH ED Workers Compensation ODGCalifornia MTUSClinical Knowledge.
Skills : Utilisation Review , Case Management.
Description :
Contracted employee through Chase Source.
Handled professional phone calls and wrote professional letters to DME/Home Health providers.
Used Medical record review.
Responsible for Prior Authorisations for Medicare and Medicaid.
Responsible for concurrent review for psychiatric population.
Assisted with Care Management and Discharge Planning for geriatric population.
Responsible for training staff.
Experience
5-7 Years
Level
Executive
Education
BS In Nursing
Prior Authorization Nurse Resume
Objective : Prior Authorization Nurse is responsible for Documenting adverse events that occur or are suspected of occurring during patient care or treatment, Reviewing, signing and dating all medical records following an incident or incident report, and also Answering questions from family members as they come into contact with a patient while receiving patient care.
Skills : Medication administration, Medical Skills.
Description :
Supported doctors and hospitals in obtaining prior authorisations for procedures, office visits, surgeries and pain injections using InterQual criteria.
Rendered exceptional customer service and meet volume deadlines and timetables.
Coordinated and communicated with providers the appropriate ICD-9 codes for each procedure.
Ensured the appropriate use of selected prescription drugs.
Coordinated and communicated with doctors to prescribe an alternate drug beneficial for the patient.
Provided authorisations and/or denials based on clinical documentation review and medical necessity.
Collaborated with Medical Director for more complex cases.
Experience
2-5 Years
Level
Executive
Education
Certification In IV Therapy
Prior Authorization Nurse Resume
Summary : Enthusiastic Prior Authorization Nurse with excellent people skills, dedicated work ethic and medical procedure competency. High-performing Manager with 37 years of healthcare experience in hospital, outpatient and medical office environments.
Skills : Microsoft, Nursing, Time Management.
Description :
Identified solutions to non-standard requests and problems.
Interfaced with other departments to coordinate workflow processes.
Reviewed authorisation requests and communicates with the physicians' offices when additional information is needed or assists office in re-directing care to an appropriate Plan provider or facility Conveys and records authorisations clearly within the notes.
Refereed cases to Medical Director when the treatment request does not meet medical necessity guidelines or when a peer-to-peer conversation is necessary to establish appropriateness.
Made referrals in a timely manner, allowing the physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within state guidelines and mandated turnaround times.
Evaluated member's quality of care by following up on cancellations and denials.
Adhered to company's policies and in accordance with URAC and Medicare.
Experience
7-10 Years
Level
Management
Education
BS In Natural Sciences
Prior Authorization Nurse Resume
Headline : Prior Authorization Nurse with 7 years of experience in Directly supervising physicians, nursing staff and other authorised personnel, Ensuring all patient care is performed in accordance with departmental policies and procedures, Working closely with physicians, nurses, medical directors and other medical staff to ensure clinical safety and quality of patient care.
Skills : Patient Care, Policy Assistant, Quality Assistant.
Description :
Completed information required for medical review process and extension letters.
Reviewed authorisation requests and associated clinical information received via fax and processes and documents according to the health plan's process and training documents.
Provided high quality patient care, including medication compliance, adherence to medical instructions, and continuity of care.
Ensured that all patient information is up to date and complete.
Ensured that the physicians office has access to all necessary patient information in order to make appropriate referrals.
Maintained records of all medical/dental appointments, medical/dental procedures, and laboratory results in order to document correct prescribing of medications and services.
Documented with a system of notes or journal entries all medical/dental appointments, medical/dental procedures, and laboratory tests performed on each patient. In addition, any information obtained from patients will be.
Experience
5-7 Years
Level
Executive
Education
BA In Nursing
Prior Authorization Nurse Resume
Objective : Educated young Prior Authorization Nurse professional looking to gain employment as a registered nurse. That allows me to utilize my current skills and abilities while fostering new skills, education and opportunities for growth, Providing direct supervision to physicians with respect to patient care, Directly supervising team members that are directly involved in patient care (e.g., nurse aides, physician assistants).
Skills : Planning, Physician Assistant, Nursing.
Description :
Provided medical care to individuals who are not eligible for admission or treatment at the facility where they reside or that they are admitted.
Ensured that the patient has all of the appropriate documentation required by law in order to complete his/her treatment plan.
Ensured that the patient has all of the necessary documents required by law in order to complete his/her treatment plan.
Assisted with patient discharge from the hospital or community setting, including transportation home.
Assisted with follow up with family members.
Provided patient information to family members or other healthcare providers.
Assisted in obtaining necessary medical records, medications, laboratory results and medical equipment.
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