Works as part of integrated team and is involved in reviews of authorization requests and communicates with the physicians and clinic when additional information is needed or assists clinical practitioner's office in re-directing care to an appropriate plan provider or facility. Performs activities that include obtaining payer authorization for outpatient services that require notification/authorization based on payer specific guidelines. Responsible for clinical part of audit to determine if all charges have been captured appropriately. Maintains a thorough understanding of the plan's provider contracts, authorization requirements and Interqual Criteria Provides ongoing follow-up and re-evaluation of clinical departments/areas as requested or needed for authorization review. Performs prior authorization and retrospective clinical review according to Interqual Criteria', Medicare Guidelines and established payer protocols to determine the medical appropriateness of ordered pre and post scheduled services. Enters authorization information into EPIC and maintains authorization data.
Education/Specialized Training/Licensure: Nurse in good standing, currently licensed in the State of Texas without stipulations in practice as an Licensed Vocational Nurse
Work Experience: Minimum 3 years of hospital experience in various clinical areas (required). 1 year utilization review, authorization or case management experience (preferred). Familiarity with hospital coding and billing processes (preferred). Knowledge of Interqual/Milliman guidelines (preferred). EPIC EMR experience (preferred).
Management Experience: Preferred but not necessary.
Equipment Operated: PC functions, calculator, general office equipment
SPECIAL REQUIREMENTS: Communication Skills: Above Average Verbal (Heavy Public Contact) Exceptional Verbal (e.g., Public Speaking)
Writing /Composing (Correspondence/Reports) Other Skills: Analytical, Mathematics, Medical Terms, P.C.
Work Schedule: Flexible
Other Requirements: Requires travel to Harris Health System facilities. Must be able to interact successfully in a culturally diverse environment.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.