Authorization Review Nurse -LVN

This position has no supervisory responsibilities.

All duties performed will be done accurately and in a timely manner.

1. Carries out GMG UM Program activities and UM operations.
2. Reviews/ works reports daily that document services discovered in the claims process that do not have appropriate authorization to process the claim.
3. Research services by various means (review of medical record, consult notes, patient input) to evaluate if claims should be authorized for payment or denied based on appropriate guidelines.
4. Summarizes medical record documentation for physician medical necessity reviews as indicated. Supplies evidenced-based criteria to medical necessity reviews and documentations appropriately in review summary.
5. Documents the decision in multiple platforms such as EMR and MSO to communicate the determination to the claims department/health plan.
6. Carries out the process in a timely manner resolving the majority of claims without authorizations within 1-2 working days, more complex determinations within 5 business days. As this impacts Claims processing timeliness.
7. Holds regular “U Status” meetings (U=unauthorized) with referral/MSO team to review complex services, develop consistency in reviews and criteria utilized.
8. Identifies opportunities for operational improvement, and works collaboratively with UM team, Case Management, Referral Department, and other GMG departments.
9. Communicates effectively regarding UM issues with patients, GMG staff/providers and external staff/providers.
10. Participates in the annual review of Managed Care, UM policies and procedures, and other periodic reviews as needed.
11. Promotes the Contracted Network Providers to GMG patients and staff.
12. Promotes teamwork in daily activities. Exercises tact and courtesy when dealing with patients / families, Network staff, Providers and co-workers.
13. Maintains strict confidentiality. Practical HIPAA knowledge and focus.
14. Other duties as assigned.