LPN - Prior Authorization Review Nurse

WellCare Health Plans, Inc. (NYSE:WCG) a Fortune 1000 company, is the nation?s leading provider of government health insurance products dedicated to government-sponsored health plans such as Medicare, Medicaid, State Children?s Health Insurance Programs, Medicare Prescription Drug Plans and others. Founded in 1985, our team of 2,500 associates and over 20,000 physician partners serve 1.4 million members across the U. S. Our company headquarters are based in Tampa, FL. For more information about WellCare, please visit the Company?s website at www.wellcare.com.

 

We are looking to add a Prior Authorization Review Nurses to our Health Services team.  If you truly believe in teamwork, consistently demonstrate a high level of integrity and want to be a part of a dynamic, growing organization, then this may be the opportunity for you.

 

Job Summary:

Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, outpatient services and out of network providers.  Reviews medical records, uses clinical expertise and compares information to established guidelines and the members benefit plan.  Works closely with departmental management staff to impact the treatment plan and identify treatment plan alternatives. 

 

Essential Functions:Utilizes Well Care designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with review determinations. Evaluates all requests for service, to determine the Company?s financial liability including the collection of information regarding subrogation and COB and entry in the Health Services system. Ensures accurate coding using CPT-4 and ICD-9 codes.  Documents all information accurately. Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information. Adheres to all confidentiality requirements. Applies appropriate benefits information to determine if requested services are a covered benefit. Applies medical knowledge and experience to authorize pre-service requests. Arranges for transfer to in-network care when appropriate. Initiates process for Letter of Agreements for out of network provider requests that meet approval criteria. Identifies cases appropriate for case management and makes appropriate referrals. Identifies potential quality of care issues and refers to the Quality Department. Meets service standards for decision turn around times and written correspondence.

 

Additional Duties:Provides superior customer service to internal and external customers. Submits required reports within departmental guidelines.

 

Knowledge, Skills, Abilities Required:Demonstrated negotiation skills. Demonstrated ability to plan, coordinate and organize. Previous experience working with treatment teams to meet the healthcare needs of participants. Knowledge of community, state and federal laws and resources. Payer experience and/or experience in InterQual preferred.

 

Education/Experience: LPN or RN  licensed in the state of the associate physical work location Minimum of 3-5 years clinical experience in an acute care facility. Managed care experience preferred.

 

Computer skills:

Microsoft Office skills required including Word, Excel and Outlook Express