Overview of Position
This position coordinates a team approach to management of patient care on an outpatient basis, acting as a liaison between Health Plan, Provider, and IPA. This position works closely with the Manager of Health Services and the Medical Director to evaluate, monitor, and assure the appropriateness, benefits/coverage, and medical necessity of selected care for members as it relates to quality, continuity, and cost effectiveness. This position is mainly responsible for the day-to-day authorization process and works closely with Case Management in identifying and coordinating the transitional needs of inpatients to outpatient care.
What will be my duties and responsibilities in this job?
- Reviews designated physician requests for referral authorization either proactively, concurrently, or retroactively.
- Acts as a liaison between capitated specialty groups and Change Healthcare.
- Gathers all information needed to make a medical determination; reviews these with the Medical Director as needed.
- Responsible for complete follow through of all referral requests including timeliness, accuracy, and appropriateness for medical indication.
- Works with appropriate to ensure supporting contracts are in place when authorizing a provider.
- Identifies cases that require case management start tickler file and coordinate the case with the case managers.
- Assists in developing and implementing standards and protocols for the Authorizations Department
- Identifies cases that need to be referred to Utilization Management Committee; gathers all supporting information needed.
- Identifies trends in physician offices that require education and communicates these to the Provider Relations department.
- Develops and maintains strong working relationships with HMOs and providers.
- Communicates with health plan representatives on costly or complicated cases.
- Documents pertinent related information in the section of the authorization.
- Adheres to and supports the mission, purpose, philosophy, objectives, policies, and procedures of Change Healthcare.
What are the requirements needed for this position?
- Education: High School Diploma or Associates degree. Bachelor’s degree preferred.
- Licensure: Must have current unrestricted California licensed Vocational Nurse or Registered Nurse.
- Minimum of three years’ experience in a managed care setting and/or recent clinical experience.
What other skills/experience would be helpful to have?
- Ability to prioritize and organize work area despite multifaceted task directions and interruptions.
- Experience and understanding of the confidentiality of medical records.
- A thorough understanding of the managed care environment from the perspective of the member, physician, and hospital.
- Ability to handle difficult people/situations.
- Excellent interpersonal skills with the ability to interface with physicians, hospital staff, members, and health plan in a tactful, informed and customer-oriented manner.
- Strong written and verbal communication skills.
What are the working conditions and physical requirements of this job?
Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!
COVID Vaccination Requirements
We remain committed to doing our part to ensure the health, safety, and well-being of our team members and our communities. As such, we require all employees to disclose COVID-19 vaccination status prior to beginning employment and we may require periodic testing for certain roles. In addition, some roles require full COVID-19 vaccination as an essential job function. Change Healthcare adheres to COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance.
Equal Opportunity/Affirmative Action Statement
Change Healthcare is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, genetic information, national origin, disability, or veteran status. To read more about employment discrimination protections under federal law, read EEO is the Law at https://www.eeoc.gov/employers/eeo-law-poster and the supplemental information at https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP_EEO_Supplement_Final_JRF_QA_508c.pdf.
If you need a reasonable accommodation to assist with your application for employment, please contact us by sending an email to [email protected] with “Applicant requesting reasonable accommodation” as the subject. Resumes or CVs submitted to this email box will not be accepted.
Click here https://www.dol.gov/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf to view our pay transparency nondiscrimination policy.
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Change Healthcare maintains a drug free workplace and conducts pre-employment drug-testing, where applicable, in accordance with federal, state and local laws.