Authorization Nurse - Clinical Care Coordination

UPMC Hamot's Clinical Care Coordination team is actively seeking the perfect candidate for their new Authorization Nurse position!

In this role, you will directly collaborate with Emergency Medicine physicians and DC planning professionals to assess level of care indicators and effectively determine the appropriate status for admissions, whether as inpatient or OBS.
Prior utilization review experience highly preferred.

The ideal candidate will work five 8-hour shifts, typically from 11 am to 7 pm, with the possibility of weekend shifts. We are open to discussing alternative schedules such as four 10-hour shifts or three 12-hour shifts for candidates who meet our criteria.

At UPMC, we’re passionate about continuing to support your growth throughout your nursing journey. We offer free MSW and MSN programs through our partnership with Capella University. Furthermore, we provide tuition reimbursement for ACMA certification and membership to support your professional development.

Join us at UPMC Hamot and be part of a dynamic team dedicated to providing exceptional patient care and fostering career growth opportunities for our employees! Apply today to embark on a rewarding journey with us!

The Authorization Nurse provides support to appropriate UPMC departments and healthcare providers by obtaining referrals and/or authorizations for any acute admissions, hospital services and treatments. Drawing on a knowledge base of acute care experience and knowledge of payer regulations, is responsible for assessing medical necessity and ensuring the presences of supporting documentation to obtain authorization. Communicates pertinent clinical information to Physicians, Medical Directors or CFO.

Responsibilities:

• Serve as a liaison between care managers and payors and facilitates payor/physician contact when indicated.
• Communicates to the Medical Directors, Attending Physicians and/or CFO, if indicated, regarding evaluation of medical appropriateness.
• Act as a resource to other departments as well as the care managers leveraging clinical expertise relative to the authorization process.
• Collaborate with other departments to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness.
• Ensure clinical review process is followed in order to meet payor deadlines.
• Report to management on an ongoing basis trends/barriers that could necessitate process improvement from a concurrent standpoint.
• Assist in determining system-wide care management needs through investigation of authorization process and identification of root cause.
• Identify and assigns a root cause to each case to ensure denial reasons are tracked.
• Monitor and evaluates for area of process improvement related to the payor specific authorization process.
• Maintain current knowledge of regulatory guidelines related to authorizations.
• Perform clinical review for cases referred for cases requiring authorization or adherence to payor medical policies.
• Maintain collaborative relationships with utilization management and departments at payor organizations.
• Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process.