The Program Manager- Prior Authorization is responsible for completing timely review and authorization request activities for the CHRISTUS Health system, ensuring the requests meet national standards and contractual requirements. Promotes quality and cost-effective patient care using clinical acumen. Direct interface to the corporate Managed Care department to escalate and bring to resolution payor related issues involving post acute prior authorizations. Works collaboratively with case management, utilization review, physician advisors, and clinical care providers to effectively manage post-acute care authorization needs. Prepares documentation, performs audits, and assists leadership team as needed. In order to be successful, the incumbent will need to work with a diverse array of internal stakeholders to develop innovative playbooks and diffusion plans and collect supporting information to evaluate the effectiveness of the work. Excellent communication skills are imperative for this role.
Promotes the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
Performs clinical reviews of prior authorization requests for appropriate care and setting, following state and federal guidelines and policies. Works to obtain approval for services or forwards requests to the appropriate clinical team members with recommendations for other determinations.
Complete medical necessity and level of care reviews for requested services using clinical judgment. Refer to Physician Advisors for review depending on case findings
Collaborate with various staff within provider networks and medical management teams electronically or telephonically to coordinate care.
Ability to communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations.
Telephonic and written communication with health care providers to explain benefit coverage determinations and to obtain additional clinical information when necessary for determinations
Telephonic and written communication with health care providers to explain benefit coverage determinations and to obtain additional clinical information when necessary for determinations.
Provides accurate and complete documentation including rationale used to approve/deny requests.
Collaborates with various staff within the provider network and health services team to coordinate post-acute care.
Collaborates with payers to maintain authorization turn-around times as prescribed by guidelines and contracts.
Identifies ways to improve work processes and improve customer satisfaction.
Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of CHRISTUS Health.
Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area.
Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements.
Seeks advice and guidance as needed to ensure proper understanding.
Function as a member of a self-directed team to meet specific individual and team performance metrics.
Work independently and collaborating with case managers, social workers, utilization review nurses, case management leaders, attending physicians, and physician advisors.
Assist in the development and maintenance of policies and procedures and program design.
Maintain ongoing communication with internal stakeholders and external partners on the development and implementation of new modalities.
Develop collaborative relationships with internal departments and external vendors that interface with the Clinical Excellence Division.
Work with internal teams to design and oversee ongoing program evaluation to ensure innovative solutions continue to yield improvements in patient care and institutional financials.
Role may require some travel.
Registered Nurse or Licensed Vocational Nurse license preferred
Bachelor's Degree in business or healthcare related field preferred.
3+ years of experience working for an insurance company, medical management, utilization review, or case management required.
Familiarity with Milliman Care Guidelines and InterQual
Demonstrate proficiency in computer skills - Windows, Instant Messaging, Microsoft Suite including Word, Excel and Outlook
Competent in prior authorization functions including application of criteria and timelines.
Ability to analyze clinical information and accurately apply clinical criteria.
Proficient in medical and managed care terminology.
Knowledge of and competence in use of prior authorization software.
Ability to multitask between computer, fax and multi-line phone requests.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.