Authorization Nurse

at  UPMC

LICENSURE, CERTIFICATIONS, AND CLEARANCES:

• Registered Nurse (RN)
• 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.

PURPOSE:

Do you have clinical care experience? Are you an RN looking to grow your career? UPMC is looking to hire 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 (typically 7:00am until 3:30pm). 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 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.
• 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.