Out Patient Case Management Nurse & Denials Nurse (2 roles) New

Imperial Health Holdings is seeking an Outpatient Case Manager, RN or LVN. Licensed in Texas and or California!

Responsible for providing timely review of authorization requests to meet national standards and contractual requirements. The prior authorization nurse will promote the quality and cost effectiveness of patient care using clinical acumen.

ESSENTIAL JOB FUNCTIONS:

1. Perform a timely review of prior authorization requests for medical necessity by applying appropriate clinical criteria.
2. Provide accurate and complete documentation with the rationale used to approve requests.
3. Collaborate with various staff within clinical services to coordinate patient care.
4. Provide appropriate interventions that demonstrate knowledge and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Use interpreter services as needed.
5. Enter and maintain clinical information in authorization systems.
6. Prepare case summaries and provide clinical criteria for cases that require MD reviews.
7. Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.
8. Maintains regular and consistent attendance.

Adheres to Compliance Plan and HIPAA regulations