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; Page 1 of 2 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. _____________________________________________________________________________________________ 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. Page 2 of 2