This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Prior Authorization Nurse (50462)
Location
United States
Posted
89 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Prior Authorization Nurse (50462)
GLOBALHEALTH HOLDINGS LLC
Job DetailsJob Location: Any Location Remote US - Oklahoma City, OK 73102Position Type: Full TimeTravel Percentage: OccasionalJob Shift: DayWHO WE ARE: GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. WHO YOU ARE: This position performs utilization management review. This position determines appropriateness of services, medical necessity, and location of services required to encourage effective, high-quality care and cost-efficient outcomes through. This position requires excellent verbal and written communication, organization and time management skills. ESSENTIAL JOB FUNCTIONS: Reviews preservice requests, appropriateness of services, and ensure timely determination Communicates with customers, both internal and external, regarding status of referral/referral process. Utilizes NCDs, LCDs, MCG, and additional guidelines to assist in determining coverage of the request. Maintains current knowledge of managed care issues (benefits, contracted providers, health plan guidelines, MCG, NCD, LCD and community standards of practice and regulatory developments, and new and experimental procedures). Collaboration with internal team to support member needs, including but not limited to discharge planning, provider relations, and care management. Adheres to company and department policies and procedures. Performs other duties as assigned Qualifications EDUCATION AND EXPERIENCE: Current active LPN license in Oklahoma/Texas or compact Experience in managed care/utilization management preferred Minimum of 3-5 years of clinical experience required KNOWLEDGE, SKILLS AND ABILITIES: Working knowledge of ICD-10/CPT codes preferred Working knowledge of Microsoft software programs Excellent organizational skills Strong communication skills Proven ability to work independently and as a member of a team WORK ENVIRONMENT: Current work environment is remote; however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies. TRAVEL: May require limited travel for offsite meetings or training SUPERVISORY RESPONSIBILITY: This position has no supervisory responsibility OTHER DUTIES: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Related Guides
Related Categories
Related Job Pages
More Medical Reviewer Jobs
HIM Operations Clinical Data Abstractor I
American Addiction CentersLeading nationwide provider of substance use treatment offering a full continuum of care. #FreedomFromAddiction
Department: 13533 Enterprise Revenue Cycle - HIM Ops Services and Support Lab Data Abstracting Status: Full time Benefits Eligible: Yes Hours Per Week: 40 Schedule Details/Additional Information: The schedule would be Friday through Sunday, plus two additional days off during the week, which can be negotiated. Hours are 8:00 a.m. to 4:30 p.m. Remote Pay Range $22.90 - $34.35 Major Responsibilities Navigates various electronic health record (EHR) and computer applications to perform job duties to support patient care, care management initiatives, revenue cycle, Health Maintenance and regulatory requirements. Receives, sorts, prepares, and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures. Analyzes non-interfaced patient laboratory reports to ensure patient identifiers and compliance with all applicable regulations including Health Maintenance, College of American Pathologist (CAP) Accreditation, and Clinical Laboratory Improvement Amendments (CLIA). Utilizes optical character recognition software to electronically and or manually enter appropriate data into the EHR. Identifies, creates, or releases the appropriate laboratory tests by applying knowledge of medical terminology and laboratory nomenclature. Selects the correct order templates, discretely enters, and validate individual components, comments, footnotes, performing laboratory name and address, collection date and time, units of measure, reference ranges, abbreviations, and symbols. Discretely abstracts and imports laboratory results and other clinical documentation into the EHR. Records normal and abnormal findings. Ensures laboratory values are accurately entered and flagged to promptly alert patients and clinicians regarding normal and abnormal results. Locates or creates the appropriate patient, encounter, and/or order. Correctly paginates and classifies documentation to the appropriate document type and description. Ensures appropriate security levels, protection, and destruction of electronic and physical PHI information according to Health Insurance Portability and Accountability Act (HIPAA). Readily adapts to new and/or evolving laboratory tests, parameters, reference ranges, and regulations. Validates all data points and laboratory codes and uses critical thinking skills to identify and investigate questionable information and troubleshoot issues. Escalates issues and reports patterns of concern to leadership timely. Performs quality assurance of scanned documentation to ensure clinical documentation is scanned to the correct patient, encounter, document type, and orderable in a timely manner according to Health Information Management policy. Verifies the electronic information against the paper document to validate accuracy, clarity, and legibility Completes timely error correction or notification process; including re-resulting or deleting documentation as needed. Ensure secure retention and destruction of electronic and physical PHI in accordance with applicable regulations and policies Communicates with patient care and external performing laboratories via phone, email, fax, Epic In-Basket, and other methods to provide education, STAT laboratory data entry services and other required information. Minimum Job Requirements Education High School Graduate or Equivalent Certification / Registration / License Experience Typically requires 1- 2 years of experience gained through working in a Health Information Management, Medical Laboratory department or other related health care setting. Knowledge / Skills / Abilities Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, Extract LabDE, Solarity, OnBase, Microsoft 365 and legacy archives. High attention to detail and accuracy with frequent interruptions. Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints. Ability to work independently and make decisions with minimal supervision while maintaining quality and productivity standards. Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve. Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success Physical Requirements and Working Conditions This position requires travel, therefore, will be exposed to weather and road conditions. Operates all equipment necessary to perform the job, performs daily routine maintenance of equipment Exposed to a normal office environment. Reliable Internet Service Preferred Job Requirements Education Experience Knowledge / Skills / Abilities All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation - Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training - Premium pay such as shift, on call, and more based on a teammate's job - Incentive pay for select positions - Opportunity for annual increases based on performance Benefits and more - Paid Time Off programs - Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability - Flexible Spending Accounts for eligible health care and dependent care expenses - Family benefits such as adoption assistance and paid parental leave - Defined contribution retirement plans with employer match and other financial wellness programs - Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.
HIM Operations Clinical Data Abstractor I
American Addiction CentersLeading nationwide provider of substance use treatment offering a full continuum of care. #FreedomFromAddiction
Department: 13533 Enterprise Revenue Cycle - HIM Ops Services and Support Lab Data Abstracting Status: Full time Benefits Eligible: Yes Hours Per Week: 40 Schedule Details/Additional Information: Monday - Friday 8am-430pm Work from home Pay Range $22.90 - $34.35 Major Responsibilities Navigates various electronic health record (EHR) and computer applications to perform job duties to support patient care, care management initiatives, revenue cycle, Health Maintenance and regulatory requirements. Receives, sorts, prepares, and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures. Analyzes non-interfaced patient laboratory reports to ensure patient identifiers and compliance with all applicable regulations including Health Maintenance, College of American Pathologist (CAP) Accreditation, and Clinical Laboratory Improvement Amendments (CLIA). Utilizes optical character recognition software to electronically and or manually enter appropriate data into the EHR. Identifies, creates, or releases the appropriate laboratory tests by applying knowledge of medical terminology and laboratory nomenclature. Selects the correct order templates, discretely enters, and validate individual components, comments, footnotes, performing laboratory name and address, collection date and time, units of measure, reference ranges, abbreviations, and symbols. Discretely abstracts and imports laboratory results and other clinical documentation into the EHR. Records normal and abnormal findings. Ensures laboratory values are accurately entered and flagged to promptly alert patients and clinicians regarding normal and abnormal results. Locates or creates the appropriate patient, encounter, and/or order. Correctly paginates and classifies documentation to the appropriate document type and description. Ensures appropriate security levels, protection, and destruction of electronic and physical PHI information according to Health Insurance Portability and Accountability Act (HIPAA). Readily adapts to new and/or evolving laboratory tests, parameters, reference ranges, and regulations. Validates all data points and laboratory codes and uses critical thinking skills to identify and investigate questionable information and troubleshoot issues. Escalates issues and reports patterns of concern to leadership timely. Performs quality assurance of scanned documentation to ensure clinical documentation is scanned to the correct patient, encounter, document type, and orderable in a timely manner according to Health Information Management policy. Verifies the electronic information against the paper document to validate accuracy, clarity, and legibility Completes timely error correction or notification process; including re-resulting or deleting documentation as needed. Ensure secure retention and destruction of electronic and physical PHI in accordance with applicable regulations and policies Communicates with patient care and external performing laboratories via phone, email, fax, Epic In-Basket, and other methods to provide education, STAT laboratory data entry services and other required information. Minimum Job Requirements Education High School Graduate or Equivalent Certification / Registration / License Experience Typically requires 1- 2 years of experience gained through working in a Health Information Management, Medical Laboratory department or other related health care setting. Knowledge / Skills / Abilities Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, Extract LabDE, Solarity, OnBase, Microsoft 365 and legacy archives. High attention to detail and accuracy with frequent interruptions. Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints. Ability to work independently and make decisions with minimal supervision while maintaining quality and productivity standards. Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve. Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success Physical Requirements and Working Conditions This position requires travel, therefore, will be exposed to weather and road conditions. Operates all equipment necessary to perform the job, performs daily routine maintenance of equipment Exposed to a normal office environment. Reliable Internet Service Preferred Job Requirements Education Experience Knowledge / Skills / Abilities All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation - Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training - Premium pay such as shift, on call, and more based on a teammate's job - Incentive pay for select positions - Opportunity for annual increases based on performance Benefits and more - Paid Time Off programs - Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability - Flexible Spending Accounts for eligible health care and dependent care expenses - Family benefits such as adoption assistance and paid parental leave - Defined contribution retirement plans with employer match and other financial wellness programs - Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.
Nature and Scope The Drug Safety Associate II will be responsible for the review, evaluation, and management of adverse event (AE) reports for all American Regent Inc., investigational and marketed products under the direction of the Sr. Manager of Pharmacovigilance. Essential Duties and Responsibilities Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. - Perform individual case safety report (ICSR) processing activities within the safety database ensuring quality and timely submission. - Perform quality checks on assigned ICSRs. - Performs reconciliation of safety data. - Participate in Study Team meetings as the Safety and Pharmacovigilance representative. - Support for Audits and Regulatory Inspections. - Support Pharmacovigilance with various ad hoc deliverables or projects as needed. - Provide coverage of dedicated adverse event reporting line during company business hours. - Interact with internal and external customers. - Maintain corporate compliance. - Perform any other tasks/duties as assigned by management. Education Requirements and Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. - Degree in Pharmacy (PharmD) or Nursing (RN) required. - Minimum of 2 years’ experience working in the pharmaceutical industry required, preferably in a Pharmacovigilance Department. - Demonstrated understanding of the assessment and processing of safety reports, including regulatory reporting obligations. - Working knowledge of validated drug safety databases (preferably ARGUS) and MedDRA - Team-oriented with excellent accountability, communication, and interpersonal skills. - Flexibility to work in a fast-paced environment for adherence to timelines. - Strong facilitation, organizational, analytical and time management skills. - Excellent computer skills in the following programs: MS Word, PowerPoint, and Excel. Expected Salary Range: $95,000-105,000 The salary range, is the minimum and maximum annual salary range of compensation for the role that the employer in good faith believes to be accurate at the time of the posting of an advertisement for the role. Actual compensation for the role will be based on a number of different factors including but not limited to the candidate’s qualifications, education, knowledge, skills and experience. American Regent also offers a competitive total rewards package which includes healthcare, life insurance, profit sharing, paid time off, matching 401k as well as a wide range of other benefits. American Regent celebrates diversity and we are committed to creating an inclusive environment for all employees. We are an Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, or protected veteran status. Applicants have rights under Federal Employment Laws. - FMLA poster: https://www.dol.gov/whd/regs/compliance/posters/fmlaen.pdf - Know Your Rights: Know Your Rights: Workplace discrimination is illegal (eeoc.gov) - Employee Polygraph Protection Act: https://www.dol.gov/whd/regs/compliance/posters/eppac.pdf Alert: We’re aware of individuals impersonating our staff to target job seekers. Please note: · All legitimate communication will come directly from a verified ARI recruiter either by phone or via an americanregent.com email address. · Our recruiting process includes multiple in person and/or video interviews and assessments. · If you are unsure about the legitimacy of a message, contact John Rossini at jrossini@americanregent.com before responding. · We never request payment, bank information, or personal financial details during our offer process. Your security is important to us, and we encourage you to stay vigilant when job searching. American Regent Inc. endeavors to make https://careers.americanregent.com/ accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please email hrtalentacquisition@americanregent.com.
Grievance & Appeals Coordinator I
Centene Corporation GroupCentene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. THIS POSITION IS FULLY REMOTE/WORK FROM HOME. TRAINING WORK SCHEDULE IS MONDAY-FRIDAY 8AM - 5PM CENTRAL TIME ZONE. THE WORK SCHEDULE AFTER TRAINING IS TUESDAY - SATURDAY 8AM - 5PM CENTRAL TIME ZONE. Position Purpose: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members. - Gather, analyze and report verbal and written member and provider complaints, grievances and appeals - Prepare response letters for member and provider complaints, grievances and appeals - Maintain files on individual appeals and grievances - May coordinate the Grievance and Appeals Committee - Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information - Assist with HEDIS production functions including data entry, calls to provider’s offices, and claims research. - Manage large volumes of documents including copying, faxing and scanning incoming mail - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: High school diploma or equivalent. Associate’s degree preferred. 2+ years grievance or appeals, claims, related managed care experience, or relevant experience. Pay Range: $19.43 - $32.98 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act


