Job Description

Authorization Nurse

Do you have clinical care experience? Are you an RN looking to grow your career? UPMC is hiring a full-time Authorization Nurse. This position works Monday through Friday, as well as rotating weekends (typically 1 every 5-6 weeks) and holidays (usually 1 per year), during daylight hours. Additionally, this position is eligible to work from home.

The Authorization Nurse provides support to appropriate UPMC departments and healthcare providers by obtaining referrals and/or authorizations for any acute admissions, hospital services, and treatments. The employee uses their knowledge of acute care experience and payer regulations to assess medical necessity and ensure the presences of supporting documentation to obtain authorization. Additionally, they communicate pertinent clinical information to Physicians, Medical Directors or CFO.

If this sounds like the position for you, apply today!

Responsibilities:

• Serve as a liaison between care managers and payors and facilitate payor/physician contact when indicated.
• Communicate to the Medical Directors, Attending Physicians and/or CFO, if indicated, regarding evaluation of medical appropriateness.
• Act as a resource to other departments as well as the care managers leveraging clinical expertise relative to the authorization process.
• Collaborate with other departments to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness.
• Ensure clinical review process is followed in order to meet payor deadlines.
• Report to management on an ongoing basis trends/barriers that could necessitate process improvement from a concurrent standpoint.
• Assist in determining system-wide care management needs through investigation of authorization process and identification of root cause.
• Identify and assign a root cause to each case to ensure denial reasons are tracked.
• Monitor and evaluate for area of process improvement related to the payor specific authorization process.
• Maintain current knowledge of regulatory guidelines related to authorizations.
• Perform clinical review for cases referred for cases requiring authorization or adherence to payor medical policies.
• Maintain collaborative relationships with utilization management and departments at payor organizations.
• Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process.
• Maintain patient certification information, enter certification data in appropriate systems and communicate certification status to floor Care Managers/insurance verification, transplant credit, etc.
• Maintain the denial management processes for concurrent denials/appeals, tracking and reporting denial information.
• Effectively communicate pertinent clinical information to the payor in order to obtain authorization for inpatient services.
• Serve as a resource on payor requirements for Severity of Illness (SI) and Intensity of Service (IS) determinations including observation and inpatient status.
• Serve as a liaison between the floor Care Managers and Payors and facilitate payor/physician contact when indicated.
• Perform medical record review as needed to provide necessary clinical information to payor.
• Monitor the collection, copying and transmittal of pertinent clinical information required to obtain insurance authorization.
• Provide prompt payor feedback to Care Managers/Social Workers enabling them to re-evaluate/re-direct the current patient plan of care in order to streamline the delivers of services.

Requirements:

• RN required; BSN or Bachelor's degree preferred.
• Licensed in practicing state.
• 5 years of acute care clinical experience.
• 2 years payer or care management experience.
• Understanding of clinical and care management process.
• Knowledge of medical necessity criteria (InterQual).
• Ability to apply InterQual criteria appropriately.
• Prior utilization review experience.
• Knowledge of payer reimbursement structure.
• Excellent customer service skills.
• Negotiation skills for obtaining appropriate level of care.
• Critical thinking/assessment skills.
• Self motivation/autonomy.
• Organization/time management and prioritization skills.
• Proficient in Microsoft Word and Microsoft Excel.
• Experience working with databases preferred.

Licensure, Certifications, and Clearances:

• Registered Nurse (RN)
• Act 34

Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran

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