Program Manager - Prior Authorization
Company: CHRISTUS Health
Location: Irving
Posted on: February 20, 2021
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Job Description:
Job Description: Description Summary: The Program Manager- Prior
Authorization is responsible for completing timely review and
authorization request activities for the CHRISTUS Health system,
ensuring the requests meet national standards and contractual
requirements. Promotes quality and cost-effective patient care
using clinical acumen. Direct interface to the corporate Managed
Care department to escalate and bring to resolution payor related
issues involving post acute prior authorizations. Works
collaboratively with case management, utilization review, physician
advisors, and clinical care providers to effectively manage
post-acute care authorization needs. Prepares documentation,
performs audits, and assists leadership team as needed. In order to
be successful, the incumbent will need to work with a diverse array
of internal stakeholders to develop innovative playbooks and
diffusion plans and collect supporting information to evaluate the
effectiveness of the work. Excellent communication skills are
imperative for this role. * Promotes the quality and cost
effectiveness of medical care by applying clinical acumen and the
appropriate application of policies and guidelines to prior
authorization requests. * Performs clinical reviews of prior
authorization requests for appropriate care and setting, following
state and federal guidelines and policies. Works to obtain approval
for services or forwards requests to the appropriate clinical team
members with recommendations for other determinations. * Complete
medical necessity and level of care reviews for requested services
using clinical judgment. Refer to Physician Advisors for review
depending on case findings * Collaborate with various staff within
provider networks and medical management teams electronically or
telephonically to coordinate care. * Ability to communicate in
writing and verbally, all types of benefit determinations including
decisions regarding coverage guidelines, contractual limitations
and reimbursement determinations. * Telephonic and written
communication with health care providers to explain benefit
coverage determinations and to obtain additional clinical
information when necessary for determinations * Telephonic and
written communication with health care providers to explain benefit
coverage determinations and to obtain additional clinical
information when necessary for determinations. * Provides accurate
and complete documentation including rationale used to approve/deny
requests. * Collaborates with various staff within the provider
network and health services team to coordinate post-acute care. *
Collaborates with payers to maintain authorization turn-around
times as prescribed by guidelines and contracts. * Identifies ways
to improve work processes and improve customer satisfaction. *
Makes recommendations to supervisor, implements, and monitors
results as appropriate in support of the overall goals of CHRISTUS
Health. * Maintains knowledge of applicable rules, regulations,
policies, laws and guidelines that impact the area. * Develops
effective internal controls designed to promote adherence with
applicable laws, accreditation agency requirements, and customer
requirements. * Seeks advice and guidance as needed to ensure
proper understanding. * Function as a member of a self-directed
team to meet specific individual and team performance metrics. *
Work independently and collaborating with case managers, social
workers, utilization review nurses, case management leaders,
attending physicians, and physician advisors. * Assist in the
development and maintenance of policies and procedures and program
design. * Maintain ongoing communication with internal stakeholders
and external partners on the development and implementation of new
modalities. * Develop collaborative relationships with internal
departments and external vendors that interface with the Clinical
Excellence Division. * Work with internal teams to design and
oversee ongoing program evaluation to ensure innovative solutions
continue to yield improvements in patient care and institutional
financials. * Role may require some travel. Requirements: *
Registered Nurse or Licensed Vocational Nurse license preferred *
Bachelor's Degree in business or healthcare related field
preferred. * 3+ years of experience working for an insurance
company, medical management, utilization review, or case management
required. * Familiarity with Milliman Care Guidelines and InterQual
* Demonstrate proficiency in computer skills - Windows, Instant
Messaging, Microsoft Suite including Word, Excel and Outlook *
Competent in prior authorization functions including application of
criteria and timelines. * Ability to analyze clinical information
and accurately apply clinical criteria. * Proficient in medical and
managed care terminology. * Knowledge of and competence in use of
prior authorization software. * Ability to multitask between
computer, fax and multi-line phone requests. Work Type: Full
Time
Keywords: CHRISTUS Health, Irving , Program Manager - Prior Authorization, Executive , Irving, Texas
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