Prior Authorization Nurse Navigator

Coordinates and integrates through review all services that require pre‑authorization, including new technology and experimental/investigational services using the clinical review algorithm and/or the responsibility to identify members that may require coordinated care management or disease management services, or transition of care services based on clinical risk scores or information gathered from pre‑authorization review of submitted clinicals.

• Registered Nurse with at least five (5) years’ experience. Three (3) of those years may be work experience as a nurse’s aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Preferred critical care or other acute care experience.
• Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90‑day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants.
• Demonstration of excellent oral, written, telephonic and interpersonal skills.
• Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.
• Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast‑paced environment, and adapt to changing processes.
• Possession of a superior work ethic and a commitment to excellence and accountability.
• Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.

• Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable.
• Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc.

• Enter data timely into pre‑authorization system and update diagnoses, procedures, medical histories, and consults.
• Determine appropriateness of pre‑authorizations using established clinical/behavioral health criteria and/or guidelines as appropriate per line of business.
• Review and evaluate relevant information including member history, medical records, group contracts, benefit design, plan limitations, exclusions, coordination of benefits and member eligibility in making decisions and recommendations that are consistent with sound medical and managed care practice.
• Appropriately forward service requests that do not meet guidelines per clinical algorithm to the medical director.
• Submit requests for Single Case Agreements and/or Letters of Agreement per process according to line of business.
• Coordinate care in collaboration with the member, family, health care team members, providers, and other resources to intervene proactively to identify needed medical and/or behavioral health services.
• Identify members that may need chronic disease navigation, complex case navigation, behavioral health, social service intervention and refer appropriately.
• Act as a liaison between member, provider, and The Health Plan.
• Collaborate and share knowledge and expertise with peers, supervisors, and other staff.
• Serve as assigned or as volunteer on departmental or company committees and attend departmental or work‑group meetings as scheduled.
• Promote communication, both internally and externally, to enhance effectiveness of medical management services.
• Identify opportunities for improvement in systems, processes, functions, programs, procedures and make recommendations to the appropriate management staff.
• Prioritize assignments/referrals appropriately and maintain flexibility as new priorities arise.
• Identify potential quality issues, variances, hospital acquired conditions and never events and refer to QI Department.
• Identify requests for new technology and communicate that data to the medical policy director.
• Takes after‑hours and weekend call on rotation as assigned (volunteer…