*Applicants must reside in Florida * *POSITION SUMMARY:* To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by: performing responsibilities associated with a sustainable, measurable, accurate, reliable and timely execution of the Prior Authorization Process. Success in this position will be based on the individual's ability to effectively prioritize and manage requests in an accountable and responsible manner and consistently meet departmental metrics of production and quality. *PRIMARY ACCOUNTABILITIES:* *Quality/No Harm:* * Maintains confidentiality and adheres to HIPAA requirements. * Maintains a clean/safe work environment. * Accurately processes prior authorization requests in accordance with member contract provisions, Medical policies, departmental policies and procedures and other plan approved guidelines e.g. CMS guidelines; standard of care guidelines, HFHP approved care guidelines. * Conforms to defined roles and responsibilities and rules of engagement between prior authorization processing and clinical decision making. * Partners with appropriate professionals to ensure strict adherence to the boundaries and timeframes set by regulatory standards and accreditation guidelines. * Refers cases to Medical Director when the treatment request does not meet medical necessity guidelines or when a peer-to-peer conversation is necessary to establish appropriateness. * Demonstrates knowledge of accreditation and regulatory Utilization Management and Case * Management standards and requirements. * Achieves individual productivity and quality metrics set by management. * Contributes towards departmental performance and quality metrics. * Conveys and records authorizations as defined by documentation policies and procedures. * Completes all necessary data entry in Medical Management Systems and approves or refers to Medical Director potential denials and documents in the Medical Management system per established protocols. * Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care in accordance with established policy. *Customer Experience:* * Provides accurate and professional service to Customers. * Demonstrates sensitivity and shows pro-active behavior in addressing customer needs. * Interacts with Health First Health Plan interdepartmental associates to resolve issues both timely and efficiently. * Responds to Customer inquiries related to: Authorization requests, decisions and extensions; * Benefit coverage and exclusions; Eligibility; Plan Providers; Claims payments and non-payments. * Customer Centric approach to daily activities and outcomes. * Identifies problems or complex cases and refers for possible case management intervention and identifies patients with chronic disease process for possible disease management intervention. * Communicates with members of the treatment team, reviews medical records, uses clinical expertise and compares information to established guidelines and the member's benefit plan. *Stewardship:* * Utilizes Health First Health Plan resources cost effectively. * Identifies and recommends alternatives in care or care setting to streamline and effectuate appropriate clinical outcome. * Responsible for coordinating the delivery of cost-effective, quality-based health care services for health plan members. * Accepts responsibility and actively participates in special projects that will positively impact and lower administrative cost. * Recognizes and communicates opportunities to decrease medical cost. * Triage issues and concerns with accuracy and refers issues effectively. *QUALIFICATIONS REQUIRED:* * Excellent attention to detail and quality of work product. * Advanced Computer Skills e.g. navigation and workflow within an EMR, Benefit Administrative system(s) or medical management applications and Microsoft Office Applications required. * Advanced understanding of Procedural and Diagnosis Coding. * Knowledge of Insurance Claims processing related to authorizations. * At least 2 years experience in Managed Care; Medicare is preferred. * 3 years work experience in a direct patient care setting; hospital acute care setting is preferred. * Prior Authorization Experience is preferred. * RN or LPN with current unrestricted Florida Licensure. *PHYSICAL DEMANDS:* * Communicating verbally by telephone. * Work effectively in a fast-paced often stressful environment. * Ability to communicate effectively with physicians, members, vendors, and other internal Health First Health Plans Associates and external customers. *MENTAL DEMANDS:* * Excellent verbal, interpersonal, and written communication skills. * Superior customer service telephone skills, including active listening and questioning skills. * Intermediate analytical and problem solving skills. * Ability to think critically in an Utilization Management and Case Management setting, define and identify risks and appropriately refer as required to appropriate team members. * Maintains a high level of motivation, initiative and accountability. * Exceptional organizational, prioritization and time management skills . * Ability to interact professionally and work effectively within a team environment demonstrating cooperation and respect. * Excellent attendance is required and ability to work a flexible schedule preferred. * Works within time constraints to meet organizational, accreditation and regulatory compliance requirements. *COMPETENCY ASSESSMENT/SKILLS CHECKLIST:* * Ability to work tactfully and effectively with team members, vendors and providers. * Ability to utilize personal computer and desk top applications: Microsoft Word, Encoder pro, CMS website, Milliman Care Guidelines, Hayes Criteria, Groupwise, ThinkHealth, Amisys Advance, Web-Portal, Sunrise, Midas. * Effective Time Management Skills. * Excellent oral and written communication skills. **Job:** **Medical Management* **Organization:** **HF Administrative Plan Inc* **Title:** *Prior Authorization Nurse Specialist HFHP - Clinical Operations * **Location:** *Florida - Brevard County-Rockledge* **Requisition ID:** *075784*