Registered Nurse, Pre-Authorization
Company: Memorial Health
Posted on: November 20, 2020
Reviews all DMH and DMG scheduled inpatient and outpatient
procedures and outpatient diagnostic services to validate the
scheduled procedure or diagnostic service has the appropriate payor
authorization or meets the payor's medical policies, there is a
valid physician order, and other clinical documentation
requirements are met prior to the scheduled procedure or diagnostic
Education and/or Other Requirements
Must be an RN or LPN with current Illinois license. Five years
experience in clinical nursing is required.
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
- Must possess good communication and interpersonal relationship
- Must be able to organize work with minimal supervision.
- Must be able to focus attention to minute details.
- Above average computer skills including Word, Excel and
software applications required. Environmental Factors
This position is performed within an environment of minimal
exposure to irritating, unpleasant, or hazardous elements or
The physical demands described are representative of those that
must be met by an employee to successfully perform the essential
functions of this job.
- While performing the duties of this job, the employee is
regularly required to sit and move through an office environment.
- While performing the duties of this job, the employee must be
able to work under stress, adapt to changing conditions, and meet
strict time guidelines.
- Ability to adhere to strict confidentiality requirements.
Reasonable accommodations may be made to assist an otherwise
qualified individual in the performance of the job. In order to
meet the needs of the Company employees may be assigned other
duties, in addition to or in lieu of those described above.
Essential Functions and Job Duties
- Understands and applies payor prior-authorization requirements,
and stays current with payor changes.
- Interacts effectively with physicians and/or office staff when
receiving information regarding hospital outpatient diagnostic
- Provides information and assistance for Utilization Review and
Patient Financial Services.
- Primary function is to receive and coordinate
pre-authorizations/RQI's on patient accounts for all outpatient
services and schedule inpatient admissions.
- Coordinates phone calls in a positive and professional manner
to meet departmental goals.
- Prioritizes scheduled patients in accordance with managed care
pre-auth requirements and medical necessity requirements.
- Utilizes the account note function to record all telephone
conversations, consultations, pertinent case specific information,
and rationale for decision on cases, all reference numbers and
- Provides excellent customer service by adhering to quality
standards and case management/confidentiality policy and
- Communicates daily with appropriate parties for prior approval
on patient accounts (case management or nurses at doctor's
- Maintains/documents accurate record of insurance/pre-auth
- Communicates barriers or process improvement opportunities to
- Assists in training new personnel or in implementing new
- Performs other duties as assigned.
Associated topics: ambulatory, cardiothoracic, care unit, ccu,
hospice, intensive, maternal, nurse, psychiatric, staff nurse
Keywords: Memorial Health, Decatur , Registered Nurse, Pre-Authorization, Healthcare , Decatur, Illinois
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