PRIOR AUTHORIZATION NURSE at The Hospital Authority of Miller County – Colquitt, Georgia

JOB SUMMARY:

The purpose of the Prior Authorization nurse is to provide timely review of authorization requests and ensure the requests meet national standards and contractual requirements. The prior authorization nurse will promote the quality and cost effectiveness of patient care using clinical acumen. As a prior authorization nurse, you review requests for authorization for specific medications, treatments, or surgeries. Duties include reviewing medical records and documents related to the application. You consider each prior authorization request and collect evidence and patient information to support your decision. You communicate with the insurance provider to obtain additional information if needed. Your responsibilities in this position also involve ensuring the authorization meets regulations and requirements and contractual obligations of all parties involved. Your job can also require coordinating with administrators and healthcare providers to gain necessary information and ensure that patients receive authorized care.

Additionally, the PA nurse will assist the clinical team with providing direct patient care services, designated independent procedures, and completing nursing tasks when needed. Provides care that meets the psychosocial, physical and general aspects of care; meets the communications needs of patient and family; provides care that reflects initiative and responsibility indicative of professional expectations, under the supervision of a registered nurse and/or physicians. Maintains regulatory requirements, nursing and office/clinic policies, procedures and standards. Communicates with physicians and team members about patient’s clinical condition, including results of diagnostic studies and symptomatology.

GENERAL REQUIREMENTS:

· Performs all job responsibilities in alignment with the mission and vision of the organization.

· Performs other duties as required and completes all job functions as per departmental policies and procedures.

· Maintains current knowledge in present areas of responsibility (i.e., self-education, attends ongoing educational programs).

· Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.

· Wears protective clothing and equipment as appropriate.

GENERAL SKILLS:

· Ability to communicate in English, both verbally and in writing.

· Additional languages preferred.

· Strong written and verbal skills.

· Basic Computer Skills

WORKING CONDITIONS:

· General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels.

· May be exposed to high noise levels and bright lights.

· May be exposed to limited hazardous substances or body fluids, or infectious organisms.

· May be required to change from one task to another or different nature without loss of efficiency or composure.

· Periods of high stress and fluctuating workloads may occur.

· May be scheduled as needed including overtime.

PHYSICAL REQUIRMENTS & DEMANDS:

· Have near normal hearing: Hear alarms/telephone/normal speaking voice.

· Have near normal vision: Clarity of vision (both near and far), ability to distinguish colors.

· Have good manual dexterity.

· Have good eye-hand foot coordination.

· Ability to perform repetitive tasks/motion.

· Continuously within shift (67-100%): Standing, Walking.

· Frequently within shift (34-66%): Bending/Stooping, Pushing/Pulling, Lift/carry up to 20lbs, Lift/carry greater than 20 lbs. with assistance.

· Occasionally within shift (1-33%): Sitting, Climbing, Twist at waist, Lift/Carry greater than 50 lbs. with assistance, Reaching above shoulder.

MISSION STATEMENT:

QUALITY HEALTHCARE: In our continuing effort to enhance the quality of life for the communities we serve, the Hospital Authority of Miller County is committed to the delivery of superior, safe, cost-effective healthcare through the provisions of education prevention, diagnosis and treatment.

JOB SPECIFIC COMPETENCIES:

· Provide timely review of authorization requests and ensure the requests meet national standards and contractual requirements.

· Provides direct patient care under the supervision of a physician PA, or NP evaluates outcomes, consults with other health team members as required and adjusts nursing care process as indicated to ensure optimal patient care.

· Ability to perform a head-to-toe assessment, under the supervision of a physician, PA or NP on all patients as per policy. This includes neonate, pediatric, adolescent and geriatric patients and the general patient population.

· Ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management.

· Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

· Performs patients care responsibilities considering needs specific to the standard of care for patient’s age.

· Demonstrates knowledge of the principles if growth and development over the life span and the skills necessary to provide age-appropriate care to the patients served. Able to interpret data about the patient’s status in order to identify each patient’s age specific needs and provide care needed by the patient group.

· Maintains current knowledge of medications and their correct administration based on age of the patient and his/her clinical condition.

· Medical and surgical asepsis is carried out during treatments and special procedures.

· Demonstrates the ability to assist physicians with procedures and perform services requiring technical and manual skills under the direction of a physician, PA and/or NP.

· Demonstrates ability to revise plan of care as indicated by the patient’s response to treatment.

· Demonstrates the ability to perform treatments and provide services to level of licensure.

· Meets current documentation standards and policies.

· Demonstrates knowledge of lab requirements, requisitions.

PROFESSIONAL REQUIREMENTS:

· Follows Code of Conduct policy.

· Adheres to dress code; appearance is neat and clean.

· Completes annual educational requirements.

· Maintains regulatory requirements.

· Maintains patient confidentiality at all times.

· Reports to work on time and as scheduled; completes work within designated time.

· Wears identification when on duty; uses computerized time clock system correctly.

· Completes in-services and returns in a timely fashion.

· Attends annual review and/or skills fair and department in-services, as scheduled.

· Attempts to end conversations and other interactions in a positive manner; leaves others with a good impression of the Hospital Authority of Miller County and its employees.

· Complies with all organizational policies regarding ethical business practices.

· Communicates the mission statement of the organization.

GUEST RELATIONS STANDARDS:

(All guest relation violations are subject to disciplinary action up to and including termination):

· Always treat others in a friendly, helpful manner.

· Refers co-workers to proper sources when unable to provide an answer.

· Interacts with others in a professional and friendly manner.

· Takes interest in others and always gives full cooperation to fellow workers.

· Always maintains an open line of communication with other departments.

· Thoroughly familiar with the hospital and the services it offers.

OTHER:

· Responsibility to Report: It is the responsibility of every employee of HAMC to comply with federal, state and local laws and regulations, as well as, HAMC Policies and Procedures. Every employee is help accountable to participate in, comply with and report concerns to his or her supervisor or the Compliance Officer if illegal or unethical behavior is suspected.

As an employee of HAMC, you have been granted user access to applicable ePHI systems based on your position. This user or role-based access is intended to give you the minimum necessary access to perform your job function(s) only and should be used only as applicable.

EDUCATION, CREDENTIALS & EXPERIENCE REQUIREMENTS:

• Current LPN licensure in State of Georgia
• Active American Heart Association BLS certification within 30 days of hire.
• Experience in doing prior authorizations preferred.