HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 200 skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.
HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care. Interested in joining our successful Garden City Team? We are currently seeking a Prior Authorizations Nurse!
Position Summary: Under the direction of the Medical Director the Prior Authorization Nurse’s primary responsibilities are to conduct prospective and retrospective reviews of authorization requests including selected specialties, medical treatments and services, elective hospital admissions, rehabilitative and ancillary services, home care and out-of-network referrals. The Prior Authorization Nurse will also assist with complex cases, internal process development and provide direction to the prior authorization coordinators to ensure documentation and timeliness standards are met.Essential Position Functions/Responsibilities:

• Review pre-service and post-service provider and member authorization requests for medical necessity and appropriateness of setting according to established policies
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures
• Perform medical necessity and level of care reviews for requested services using clinical judgement, CMS, MCG and health plan guidelines
• Maintain departmental and regulatory timeframes for decisions
• Refers appropriate prior authorization requests to the Medical Director
• Address gaps in care
• Makes appropriate referrals to other clinical programs
• Adheres to UM policy and procedure
• Meets or exceeds production and quality metrics
• Responsible for working closely with the manager to address issues and delays that can cause a failure to meet or maintain compliance

• Telephonic discussion with health care providers and/or members to explain benefit coverage
• Clinical resource for Prior Authorization Coordinators
• Educate practitioners as needed on the authorization process
• Respond to health plan inquiries and requests
• Assists in the development, review and revision of departmental policies and procedures

• Other duties as assigned

Qualification Requirements:Skills, Knowledge, Abilities 

• Knowledge of MCG Guidelines
• Familiarity with National Coverage Determinations and Local Coverage Determinations
• Demonstrated experience with evaluating medical and health care delivery issues
• Strong time management and prioritization skills
• Excellent communication (verbal and written) customer service with patients, staff, and Payers
• Knowledge of ICD 10 and CPT coding
• Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)

Training/Education: 

• Current, active, and unrestricted RN license
• Graduate from an accredited school of nursing

Experience:

• 3-5 years clinical practice with managed care, hospital nursing or utilization management experience
• 1-3 years Prior Authorization / Utilization Management experience preferred

Salary:

• Annual Base Compensation: $85,000-$100,000
• Bonus Incentive: Up to 5%, based on organizational performance

HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Department: Medical Management
This is a non-management position
This is a full time position