Prior Authorization Review LPN
- Determines compliance to pre-established medical necessity criteria applying payer-specific criteria (e.g., Medicare, Medicaid, commercial plans) and clinical guidelines to determine authorization eligibility.
- Identifies cases requiring potential or actual use of medically inappropriate interventions and refers to Medical Director for review.
- Coordinate with physicians, specialists, and facilities for missing documentation or clarifications
- Escalate complex cases to UM Manager or physician reviewer as required by protocol.
- Identify and report to Quality Management Department any potential quality of care issue and/or pre-established U.M. Referral Indicators.
- Document all authorization activities in the designated authorization platform.
- Ensure accurate entry of diagnosis codes, CPT/HCPCS codes, and clinical rationale.
- Maintain compliance with HIPAA and organizational privacy policies.
- Adhere to NCQA, URAC, CMS, and other applicable regulatory standards.
- Provide education to clinical staff regarding documentation requirements for PA approvals.
- Respond to health plan inquiries and requests , and report and submit all pertinent data in a timely manner.
- Collaborate with providers on alternatives for denied or non-covered services.
- Participate in quality assurance activities to improve PA workflows.
- Track and report on authorization turnaround times, approval/denial trends, and delays.
- Support audits and process improvement initiatives within the utilization management team.
- Actively participate in cross-departmental training to develop a deeper understanding of departmental operations and contribute to a more versatile team
- Performs other duties as directed by management.
Skills, Knowledge, Abilities
- Experience using MCG Criteria, National Coverage Determinations and Local Coverage Determinations
- Familiarity with ICD-10, and CPT coding.
- Understanding of payer policies and medical necessity criteria.
- Prior experience with EMR and PA systems (e.g., Epic, EZ-Net).
- Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)
- Excellent critical thinking and decision-making abilities.
- Strong written and verbal communication.
- Ability to multitask and prioritize in a fast-paced environment.
- Detail-oriented and organized with strong documentation practices.
- Current NY State LPN license in good standing
- Graduate of an accredited LPN/LVN program.
- 1–3 years of experience in utilization management, case management, insurance, or clinical nursing preferred.
Annual Base Compensation: $70,000 - $85,000 per year
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.
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