Position Title:
Position Status:
Reports To:
Effective Date:
Prior Authorizations Nurse-LVN
Exempt
Utilization Management Manager - Prior Authorization
12/03/10, 11/15/12
SUMMARY DESCRIPTION: Under the direction of the Utilization Management (UM)
Manager, Prior Authorizations the Prior Authorizations Nurse-LVN, acting within the scope of
the Board of Vocational Nursing and Psychiatric Technicians of the State of California, ensures
that prior authorizations requests are completed in a timely fashion to meet contractual
requirements and ensures that all reviews are conducted using nationally recognized and
evidence based standards; Participates in Quality Improvement Projects as directed; Performs
audits of medical records as directed; and Assists the U M Manager, Prior Authorization and
department Directors in preparation for audits and other regulatory activities.
DUTIES AND RESPONSIBILITIES:
% of Time
95%
Essential:
1. Acting within the scope of the Board of Vocational Nursing and Psychiatric Technicians of
the State of California, ensures that prior authorizations requests are completed in a timely
fashion to meet contractual requirements and ensures that all reviews are conducted using
nationally recognized and evidence based standards, with duties including but not limited to:
Coordinates and follows the established preauthorization review process for outpatient
and inpatient services;
Performs screening of authorization requests for Alliance members under 21 years of
age for identification and referral to California Children’s Services (CCS) as
appropriate;
Provides liaison with CCS, as assigned, for initial determination of CCS referrals and
ongoing coordination of care for authorization requests pertaining to CCS eligible
conditions;
Updates system files related to CCS determinations;
Coordinates benefits, of members under age 21, through collaboration with CCS staff
for designated Alliance County assignments;
Collaborates as directed with a Prior Authorization RN for Alliance members with
complex medical conditions;
Accurate, thorough and efficient review of authorization requests;
Timely review of prior authorization requests, both inpatient and outpatient;
Acute hospital pre-admission / Skilled Nursing Facility / Hospice and other Long
Term Care facilities; and
Surgical / Diagnostic procedures / Therapies / Durable Medical Equipment and
Home Care;
Determines utilization decisions based upon nationally recognized and evidence based
guidelines adopted by the Alliance such as Milliman Care Guidelines;
Accurate and efficient use of Alliance Care Tracking (ACT) – utilization management
software;
Produces volume of work to meet position requirements;
Evaluates patient medical records when determining benefit coverage including
appropriateness and level of care;
Reviews prior authorization requests with Medical Directors as directed;
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Prepares Notices of Action that meet contractual requirements;
Assists Member Services, Claims and Provider Services department staff with issues
that require medical interpretation or definition;
Communicates with physicians, ancillary providers and county service agencies to
coordinate member care; and
Updates and processes member / provider information as directed.
1%
2.
Participates in Quality Improvement Projects as directed.
1%
3.
Performs audits of medical records as directed.
1%
4.
Assists the UM Manager, Prior Authorization and department Directors in preparation for
audits and other regulatory activities.
2%
Secondary:
5. Performs other duties as assigned.
EDUCATION AND EXPERIENCE:
Current unrestricted California Licensed Vocational Nurse license;
Minimum two (2) years of experience in a patient care setting preferred;
Minimum one year experience in Utilization Management, case management or equivalent preferred.
KNOWLEDGE AND ABILITIES:
Strong clinical nursing background;
Knowledge of utilization management principles and activities;
Knowledge of case management principles and activities;
Ability to communicate effectively both orally and in writing;
Current working knowledge of Milliman Care Guidelines in review determination process.
Strong critical thinking skills;
Ability to use MS Word preferred;
Knowledge of Medi-Cal and related policy and Title 22 regulations;
Understanding of concepts pertaining to prepaid health care;
Ability to evaluate medical records and other health care data;
Ability to exercise good judgment and tact in relating to health care providers and beneficiaries;
Ability to establish and maintain effective and cooperative working relationships with Alliance staff and others
contacted in the course of the work;
Ability to accurately complete tasks within established times frames;
Ability to effectively prioritize multiple tasks and deadlines;
Ability to protect confidentiality of utilization management activities, quality management information and
beneficiary identification;
Valid California Driver License, transportation and automobile liability insurance in limits acceptable to the
Alliance.
WORK ENVIRONMENT AND PHYSICAL DEMANDS:
Ability to sit in front of and operate a video display terminal for extended periods of time;
Ability to bend, lift, and carry objects of varying size weighing up to 25 pounds.
All Alliance employees are expected to:
Comply with all Alliance safety requirements;
Adhere to all Alliance policies and procedures.
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The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in
this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Alliance
reserves the right to revise this job description at any time.
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