LPN Prior Authorizations Job Opening

We are actively seeking an LPN with strong experience in Prior Authorizations to join our healthcare team in Linthicum Heights, MD.

This is a 4-6 month contract to start, but could go perm.

Scope and Purpose of Position

This Prior Authorization Nurse will perform reviews of prior authorization requests for appropriate care and setting while following guidelines and policies. The Prior Authorization Nurse will approve certain services or forward requests to the appropriate Physician or Medical Director with recommendations for other determination. Other responsibilities include the coordination of the prior authorization process by reviewing clinical information received from members and/or providers for ophthalmology services. The Prior Authorization Nurse will assist with the coordination of obtaining missing clinical information, medical management, and nonstandard eyewear authorization.

Essential Functions for Prior Authorization Nurse

• Review and collect medical information in order to determine the medical necessity of services requested
• Apply specific medical criteria.
• Evaluate for complete and accurate medical information when requesting additional information
• Ensure services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized
• Initiate direct communication with health care providers to obtain complete and accurate information
• Identify appropriate clinical settings for services being requested
• Identify and refer cases for second level review
• Identify any potential quality of care issues and refer to Quality Department
• Ability to follow and apply all regulatory requirements for assigned markets
• Determine appropriate utilization management of services requested
• Assist with implementation of healthcare initiatives by market
• Assist in implementation of specific strategies that improve quality and outcomes of care
• Authorization of surgical requests according to set plan guidelines and algorithms
• Verification of eligibility, confirmation of benefits, facilitation of the referral/authorization processes

Required for Prior Authorization Nurse:

• Must be a LPN in the state of Maryland 2+ years
• Must have 1-2+ years of experience as Prior Authorization Rep (ideally with a vision background)
• Previous Optometry and/or Ophthalmology experience preferred
• Authorization of surgical requests according to set plan guideline
• Direct communication with the Medical Director with regard to surgical authorizations and non-standard services
• Preparation and coordination of denial letters
• Assist with other duties as may be assigned
• Create and maintain master spreadsheet to record all surgical procedures, denials, approvals

Interested in learning more? Apply today! We will be contacting all qualified candidates immediately.

Job Types: Full-time, Contract

Experience:

• Prior Authorization: 1 year (Preferred)

License:

• LPN (Preferred)

Contract Length:

• 3 - 4 months
• 5 - 6 months

Full Time Opportunity:

• Yes