Only applicants from the state of Oregon, Washington, Colorado and Arizona will be eligible for this position.
This position is responsible for processing prior authorization requests for a health insurance company by performing the following duties and other duties as assigned.
- Determines eligibility and benefits of members.
- Uses Oregon Health Plan prioritized list and criteria sets and/or Medicare NCDs, LCDs and policies and procedures in order to make coverage determinations.
- Determines appropriate level of care and cost effectiveness of services provided to the member.
- Acts as a resource to non-licensed Utilization Review staff, using medical background and expertise to provide input.
- Organizes and prioritizes work to meet contractual deadlines.
- Approves authorization requests if standard criteria are met.
- Appropriately refers to Medical Director for review of authorizations if standard criteria is not met.
- Documents authorization review which includes requests, evaluations, and decisions (RED).
- Refers members for case management services who have complex case management, transition of care, disease management or other identifiable needs for coordination of the member's health care.
- Utilizes critical thinking skills, clinical judgement and the nursing process to evaluate the need for requested clinical services, processes or facility use.
- Maintains a positive working relationship with other agencies and providers including out of area.
- Maintains a positive working relationship with other agencies and providers including out of area.
- Maintains confidentiality and complies with HIPAA rules and regulations.
- Maintains punctual, regular and predictable attendance.
- Works collaboratively in a team environment with a spirit of cooperation.
- Displays excellent communication skills including presentation, persuasion, and negotiation skills required in working with members and coworkers and including the ability to communicate effectively and remain calm and courteous under pressure.
- Respectfully takes direction from manager.
EDUCATION and/or EXPERIENCE
Associate degree or equivalent in Nursing from two-year college or technical school; and two to four years related experience and/or training.
COMPUTER SKILLS
Job requires specialized computer skills. Must be adept at using various applications including spreadsheet, report writing, graphics, word processing, communicate by e-mail and use scheduling software.
CERTIFICATES, LICENSES, REGISTRATIONS
This position requires an Oregon Nursing license.
We provide a competitive salary and 401(k) pension plan. To apply for this position, please submit a cover letter and resume. We are an Equal Opportunity Employer.
Job Type: Part-time
Pay: From $37.00 per hour
Benefits:
Schedule:
- Day shift
- Monday to Friday
Work Location: Remote