Prior Authorization Nurse
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Augusta, ME 04330
Transforming the future of healthcare isn’t something we take lightly. It takes teams of the best and the brightest, working together to make an impact.
*As one of the largest healthcare technology companies in the U.S., we are a catalyst to accelerate the journey toward improved lives and healthier communities.Here at Change Healthcare, we’re using our influence to drive positive changes across the industry, and we want motivated and passionate people like you to help us continue to bring new and innovative ideas to life.
If you’re ready to embrace your passion and do what you love with a company that’s committed to supporting your future, then you belong at Change Healthcare.*
Pursue purpose. Champion innovation. Earn trust. Be agile. Include all.
Empower Your Future. Make a Difference.
- Responsible for developing a working knowledge of Maine Medicaid Prior Authorization Medical Policy and contractual performance requirements and suggest potential improvements and/or changes as appropriate.
- Manage and disposition the Prior Authorization (PA) as may be assigned.
- Perform day to day activities required for PA processing and follow defined business rules and policies, including timeliness requirements.
- Work with the Medical PA unit staff members to monitor work queues and complete assigned tasks.
- Escalate difficult clinical or complex reviews/dispositions to the Operations supervisor based on business rules and workflows policies.
- Provide supporting clinical information and documentation for escalated PAs
- Respond to questions and concerns from interested parties regarding the PA criteria and processes.
- Assist in the training and development of the Administrative staff members and new nursing staff to improve PA response times and workflows.
- Participate in the preparation for and attend administrative hearings providing clinical and policy input.
MINIMUM JOB Qualifications
Education / Training:
- RN with four year degree preferred; will consider two year degree with relevant experience; State of Maine Nursing License required.
- Minimum of one year experience in Healthcare, preferably Medicaid Pharmacy or Medical claims.
- Working understanding of managed care desired but not required.
- Demonstrated ability to meet deadlines, organize multiple tasks, solve problems, communicate complex ideas and work collaboratively with clients and other partners.
SPECIALIZED KNOWLEDGE / SKILLS
- Good communicator with strong written and oral skills, including excellent spelling and grammar
- Excellent customer service skills
- Must possess and demonstrate good problem solving and critical thinking skills
- Intermediate-Advanced MS Office Suite skills
- Attention to detail
- Ability to work well under pressure in a fast-paced, time sensitive environment with shifting priorities and multiple deadlines
- Must be extremely detail oriented
- Good presentation skills
- Must be flexible and cooperative
- Must be able to learn quickly and grasp new procedures and concepts
- Ability to maintain strict confidentiality
- Ability to work and effectively deal with multiple types of personalities in a variety of situations
- Must be results driven
- Professional presentation
- Must be self-motivated and research oriented
- Environment – Office environment.
- Physical Requirements – Sitting, standing, walking, and using key board.
Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!
Equal Opportunity/Affirmative Action Commitment
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
Change Healthcare is an Equal Opportunity Employer. Employment at Change Healthcare is based upon your individual merit and qualifications. We don’t discriminate on the basis of race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, marital status, protected veteran status or disability, genetic characteristic, or any other characteristic protected by applicable federal, state or local law. We will also make all reasonable accommodations to meet our obligations under the Americans with Disabilities Act (ADA) and state disability laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability.