Prior Authorization Nurse - Medicaid AZ Remote

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.
This position is remote within the state of AZ only
PURPOSE OF THE JOB
Under the direction of the Prior Authorization Management (PA), ensures prospective review/prior authorization requests are
completed in a timely fashion to meet contractual requirements and ensures all reviews are conducted using nationally
recognized and evidence-based standards.
QUALIFICATIONS
REQUIRED QUALIFICATIONS
1. Required Work Experience
• 2 years of clinical experience
• 1 year of Medicaid/Medicare experience
• 1 year of experience managing multiple projects
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
• 1 year of experience in managed care
• 1 year of experience in prior authorization/utilization review
2. Preferred Education
• Bachelor's Degree in Nursing
3. Preferred Licenses
4. Preferred Certifications
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
ALL LEVELS
• Ensures prior authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements.
• Coordinates and follows the established preauthorization review process for pre-service requests.
• Ensures all reviews are conducted using nationally recognized and evidence-based standards.
• Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request to the Medical Director for determination when criteria is 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.
• Assists the management team and others in preparation for audits and other regulatory activities.
• Assists with other departments and special projects as needed
RN
• Performs audits of case files and staff documentation as directed
• Assists with orientation and training of all staff
• Assists with annual criteria review
• Assists with implementation of process changes as needed
Each progressive level includes the ability to perform the essential functions of any lower levels. Perform all other duties as assigned.
The position requires a full-time work schedule. Full-time is defined as working at least 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
• Ability to use electronic medical management systems
• Analytical problem solving skills
2. Required Professional Competencies
3. Required 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.