JOB SUMMARY
The R.N./LPN assumes responsibility/accountability for a group of patients for a designated time frame and provides care to these patients via therapeutic use of self, the nursing process, the environment, and other health care team members. The Prior Authorization Specialist is responsible for obtaining prior authorizations for all procedural orders and medications by successfully completing the authorization process with all commercial payers, and specialty pharmacies. Ages served range from pediatric to geriatric.
ESSENTIAL FUNCTIONS
1. Responsible for planning, assessing, intervening, co-coordinating and providing direct patient care by utilizing critical thinking skills.
2. Communicates with physicians, ancillary caregivers, patients and families regarding the patient’s plan of care.
3. Communicates with patients on an age-appropriate level.
4. Strong organization and leadership skills.
5. Recognizes and meets the needs of special needs patients, physicians, visitors, and facility staff.
6. Performs assessments including physical, psychosocial, nutritional, functional, safety, spiritual, cultural, and educational needs.
7. Completes supporting documentation for supplies, medications, labs, charges, and equipment used.
8. Contacts insurance companies to verify patients’ insurance eligibility, benefits and requirements.
9. Requests, tracks and obtain prior authorizations from insurance carriers within time allotted for medications, testing, etc.
10. The Prior Authorization Specialist is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all commercial payers, and specialty pharmacies
11. Will be expected to work closely with the Rheumatology Nurse, Infusion nurse and pharmacy staff to ensure timely, high-quality, cost-effective care
12. Verifies infusion order in the medical chart
13. Prioritize incoming authorization requests and verification of benefits according to urgency
14. Utilizes technology and resources (systems, telephones, etc.)
to appropriately complete prior authorization activities
15. Effectively and accurately communicates and documents prior authorization process to patients, providers, and department leadership
16. Interact with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria
17. Follows up on pending referrals, missing clinicals, and other items needed for criteria completion within a timely manner
18. Verifies patient has completed necessary labs prior to infusion
19. Documents in the clinic record (Chief Complaint, vitals, past medical history, medications, pharmacy, allergies, height, weight, smoking status, cessation offered if a smoker, fall risks, depression screenings and any other quality measures that are required by our organization
20. Demonstrates competency in skills verified by Skills Check List.
21. Demonstrates patient and associate safety issues by regular and proper use of certain equipment that assists in patient care (Data scopes, EKG machine, wheelchairs, etc.)
22. Follows all MCH policies and procedures.
23. Reviews various test results and takes appropriate actions.
24. Makes nursing decisions regarding patient status and immediate care needs.
25. Accurately reconciles and administers all medications.
26. Provides patient and family education and makes referrals to other internal/external providers/agencies.
27. Demonstrate compassion, empathy, and respect to all customers.
28. Operates as a team with other Clinical Nursing staff with the potential to float intermittently to help other departments due to high demand of coverage needed in other clinic areas.
29. Considers the cost of supplies with the delivery of care for each patient.
30. Attends a minimum of 50% of unit meetings offered and completes all mandatory educational requirements including skill validation.
31. Participates in Unit based Quality Improvements Projects and routine Quality and Environmental monitoring.
32. Maintains unit specific competencies and participates in review of the high-risk/ low-frequency competencies.
33. Identifies opportunities to improve patient care and utilize evidence-based resources to optimize nursing practice.
34. Maintains knowledge of equipment and continuously learns new technology and is able to trouble shoot equipment, report malfunctioning equipment and ensure its repair and return to service
35. Demonstrates and actively promotes an understanding and commitment to the mission of Morrison Community Hospital.
36. Potential need to travel to satellite clinic in the Quad City area, once a week with Rheumatology staff.
37. Maintains a working knowledge of applicable Federal, State and Local laws and regulations, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behaviors.
QUALIFICATIONS
1. Active registration for Registered Nurse, or License Practical Nurse for the State of Illinois and Iowa
2. Must be BLS certified.
3. Experience preferred.
4. Must be able to demonstrate basic computer skills in a Windows environment.
5. Must be comfortable operating in a collaborative, shared leadership environment.
6. Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring.
