The Prior Authorization Nurse Coordinator, coordinates the activities which pertain to the Prior Authorization Department. The Nurse Coordinator is responsible for ensuring all medication prior authorizations are completed across the organization as well as, facilitating procedure related pre-certifications that have escalated to a peer-to-peer or clinical appeal level. The Nurse Coordinator is responsible for providing the necessary supporting documentation in collaboration with a group of diverse health care providers.
1. Coordinate the activities which pertain to the Enterprise Prior Authorization Department.
2. Obtain medication prior authorizations from insurance entities utilizing (Covermymeds or Surescrips) in accordance with standard written procedures, guidelines, and state and federal regulations while also, maintaining compliance to medical record confidentiality regulations.
3. In coordination with the Financial Clearance team, this RN will manage peer to peer escalation cases for pre-certification and appeals for medical necessity denials.
4. Manage correspondence with insurance entities, physicians, specialists and patients as required and ensuring all necessary supporting documentation is provided for approvals.
5. Manage denials and submit appeals and ensuring all necessary supporting documentation is provided to get them approved from insurance entities.
6. Create accurate and consistent documentation in patient’s records to ensure that prior authorization information is properly updated. Record all prior authorization phone calls, documents and authorization numbers in EPIC utilizing the patient chart and referral module.
7. Utilize the patient medical record to submit supporting clinical records and/or providing verbal medical necessity validation and support for pending pre-certifications.
8. Manage physical medical records and utilization management documentation from insurance entities to support approval of pre-certifications.
9. Establishes and maintains rapport and an effective working relationship among a group of diverse health care providers.
10. Acts as a liasion between the providers and the insurance companies.
11. Acts as a resource to hospital personnel with regard to the care and coordination of medication prior authorizations and well as pre-certifications.
12. Performs job functions adhering to the Service Principles with customer service focus of innovation, service excellence, and teamwork to provide the highest quality care and service to our patients, families, co-workers, and others.
13. Other job functions as assigned.
1. A BSN degree from an accredited school of nursing and current licensure as a registered professional
nurse in the State of Illinois required. Master's prepared preferred.
2. Candidate must have 3-4 years of nursing experience. With a minimum of 1 year of medication prior
authorization and/or pre-certification experience preferred.
3. Experience working in partnership with health care professionals and support staff in an office setting is
4. Must demonstrate the ability to problem solve and support teamwork in a multidisciplinary setting in a positive
and professional manner. The candidate must demonstrate excellent written and verbal communication skills.
5. Knowledge of online authorization systems and status review and ability to track in-process authorizations
from multiple sources. Computer skills required.