Prior Authorization Nurse - Medicaid (Hybrid)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

PURPOSE OF THE JOB

Ensures accuracy and timeliness in the completion of prior authorization (PA) requests to meet contractual requirements and ensures all reviews utilize nationally recognized and evidence-based standards for the Medicaid Segment which includes Medicaid and Medicare Advantage / Dual Eligible Special Needs Plan (D-SNP), and Affordable Care Act (ACA) members. Ensures the completion, accuracy, and timeliness in the Notice of Action (NOA) process.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

· 3 years of clinical experience

· 1 year of Medicaid/Medicare experience

· 1 year prior authorization and member and provider notification (NOA) experience

· 1 year experience with National Committee for Quality Assurance (NCQA) standards

2. Required Education

· Associate degree in Nursing

3. Required Licenses

· Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health

professional, including RN or LPN.

4. Required Certifications

· N/A

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

· 3+ years of experience in managed care

· 3+years of experience in prior authorization/utilization review

2. Preferred Education

· Bachelor of Science in Nursing

3. Preferred Licenses

· N/A

4. Preferred Certifications · N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

ALL LEVELS

· Ensures the accuracy and timeliness of prior authorization requests to meet contractual requirements.

· Coordinates and manages the established preauthorization review process for pre-service requests.

· Ensures the use of nationally recognized and evidence-based standards in the completion of all pre-service reviews.

· Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request(s) to the medical director for determination when criteria not met.

· Clearly define and document review rationale to support approval, Medical Director Review and/or Notice of Action document.

· Initiates interdepartmental coordination to ensure quality and timely care for members.

· Participates in Quality Improvement Projects as directed.

· Participate in department audits and other regulatory activities.

· Engage cross-functionally and participate in special projects as needed.

· Performs Notice of Action (NOA) process.

· Participate in annual policy and procedure review and revision.

· Perform all other duties as assigned.

· The position requires a full-time work schedule,40 hours per week, plus any additional hours as requested or as needed to meet business requirements.

COMPETENCIES

REQUIRED COMPETENCIES

1. Required Job Skills

· Computer skills to include Microsoft Office applications, Word, Excel, and Outlook

· Ability to use electronic medical management systems

· Analytical problem solving skills

2. Required Professional Competencies

· N/A

3. Required Leadership Experience and Competencies

· N/A

PREFERRED COMPETENCIES

1. Preferred Job Skills

2. Preferred Professional Competencies

3. Preferred Leadership Experience and Competencies

Our Commitment

AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.