UM Prior Authorization Nurse LVN Or LPN

People. Passion. Purpose.

At P3 Health Partners, our promise is to guide our communities to better health, unburden clinicians, align incentives and engage patients. We are a physician-led organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care, transforming it from sickness care into wellness guidance.

We are looking for a Prior Authorization Nurse. If you are passionate about your work; eager to have fun; and motivated to be part of a fast-growing organization in Stockton, CA, then you should consider joining our team.

Overall Purpose: The UM Nurse is responsible for compliance with the Medical Management Program Description of P3 Health Partners regarding Utilization Review, inclusive of prior authorization, concurrent and retrospective review, discharge planning and transitions of care to the appropriate level. The UM Nurse adheres to the standard operating procedures that support achieving the Quadruple Aim: improved outcomes, improved patient experience, improved clinician experience and decreased cost of care. The UM Nurse will integrate the functions of utilization review, discharge planning and resource management into a singular effort to ensure, based on patient assessment and best practice, that care is provided in the appropriate setting utilizing medically indicated, contracted resources.

Essential Functions:

• Promote the mission, vision and values of P3 Health Partners

• Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies and approve services as per policy or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations

• Obtain additional clinical information from requesting provider or other sources when necessary for determinations

• Complete medical necessity and level of care reviews for requested services using clinical judgment. Refer to Medical Directors for review depending on case findings

• Collaborate with various staff within provider networks and Medical Management teams electronically or telephonically to coordinate care

• Educate providers on utilization and Medical Management processes

• Provide clinical knowledge and act as a clinical resource to non-clinical team

• Enter and maintain pertinent clinical information in various Medical Management systems

• Address gaps in care

Required Qualifications:

• Current, unrestricted California Nursing license

• 2+ years of experience in managed care OR 5+ years of nursing experience

• Proficient in PC Software computer skills

Preferred Qualifications:

• Prior Authorization experience

• Telephonic and/or telecommute experience

• Utilization Review / Management experience

• ICD-10, CPT coding knowledge / experience\

• InterQual experience

• Excellent communication skills both verbal and written skills

• Solid problem solving and analytical skills

• Ability to interact productively with individuals and with multidisciplinary teams with minimal guidance

• Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)