Authorization Nurse RN 26-66
$110,000–$123,350 year
On-site · San Ramon, California, United States or Stockton, California, United States
Job Summary
Evaluate authorization requests and authorize, pend or modify per criteria; obtain additional medical information as necessary; communicate with providers and members regarding status of authorization requests; collaborate with Medical Directors and other designated physician leaders for clinical decisions; utilize medical necessity criteria including Milliman Care Guidelines and Hill Guidelines to determine appropriate authorization decisions; assist interdepartmental staff to resolve issues related to the authorization process; refer information regarding members to other departments for follow-up; process routine, urgent and retrospective authorization requests according to department performance standards; support Medical Management team authorizations, clinical initiatives, provider education, and special projects; participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.
Required Qualifications
- Active, unrestricted California Licensure: Registered (RN) or Licensed Vocational Nurse (LVN)
- Minimum three years clinical nursing experience
- Utilization Management experience preferred
- Managed care experience and certification preferred
- Knowledge of ICD-10 and CPT coding
- Excellent verbal and written communication skills
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