Authorization Nurse

UPMC; United States; Remote; USD 65,000 - 85,000; Full time

Job summary

UPMC is seeking a full-time Authorization Nurse to facilitate communication between care managers and payors. This role involves performing clinical reviews and collaborating with various departments to ensure proper authorization processes. The position offers remote work eligibility and a structured schedule.

Qualifications

• Must have clinical care experience as an RN.

Responsibilities

• Serve as a liaison between care managers and payors.
• Collaborate with departments to ensure necessary information is obtained.
• Perform clinical reviews for cases requiring authorization.

Skills

Clinical Care Experience

Communication

Education

Registered Nurse (RN)

Job description

Purpose:

Do you have clinical care experience? Are you an RN looking to grow your career? UPMC is hiring a full-time Authorization Nurse. This position works Monday through Friday, with rotating weekends (typically 1 every 5-6 weeks) and holidays (usually 1 per year), during daylight hours. It is eligible for remote work.

Responsibilities:

1. Serve as a liaison between care managers and payors, facilitating contact between payors and physicians when necessary.
2. Communicate with Medical Directors, Attending Physicians, and CFO regarding the evaluation of medical appropriateness.
3. Act as a resource for other departments and care managers, leveraging clinical expertise in the authorization process.
4. Collaborate with departments to ensure all necessary information and documentation are obtained to support authorization, level of care, and medical appropriateness.
5. Follow the clinical review process to meet payor deadlines.
6. Report ongoing trends and barriers to management that may require process improvements.
7. Investigate authorization process issues to identify system-wide care management needs and root causes.
8. Track denial reasons by identifying and assigning root causes to cases.
9. Evaluate and monitor process improvements related to payor-specific authorization procedures.
10. Maintain current knowledge of regulations related to authorizations.
11. Perform clinical reviews for cases requiring authorization or adherence to payor policies.
12. Build and maintain collaborative relationships with utilization management and payor departments.
13. Provide ongoing education and feedback to care managers and other departments regarding payor-specific authorization processes.