LVN Pre/Authoriz Nurse Auditor

Harris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor Harris Health's robust network of 39 clinics, health centers, specialty locations and virtual (telemedicine) technology. Harris Health is among an elite list of health systems in the U.S. achieving Magnet® nursing excellence designation for its hospitals, the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty, residents and researchers from Baylor College of Medicine; McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth); The University of Texas MD Anderson Cancer Center; and the Tilman J. Fertitta Family College of Medicine at the University of Houston.

JOB SUMMARY

Works as part of integrated team and is involved in reviews of authorization requests and communicates with the physicians and clinic when additional information is needed or assists clinical practitioner's office in re-directing care to an appropriate plan provider or facility. Performs activities that include obtaining payer authorization for outpatient services that require notification/authorization based on payer specific guidelines. Responsible for clinical part of audit to determine if all charges have been captured appropriately. Maintains a thorough understanding of the plans provider contracts, authorization requirements and Interqual Criteria Provides ongoing follow-up and re-evaluation of clinical departments/areas as requested or needed for authorization review. Performs prior authorization and retrospective clinical review according to Interqual Criteria, Medicare Guidelines and established payer protocols to determine the medical appropriateness of ordered pre and post scheduled services. Enters authorization information into EPIC and maintains authorization data.

MINIMUM QUALIFICATIONS

Education/Specialized Training/Licensure:

Nurse in good standing, currently licensed in the State of Texas without stipulations in practice as an

Licensed Vocational Nurse Work Experience:

Minimum 3 years of hospital experience in various clinical areas (required). 1 year utilization review, authorization or case management experience (preferred). Familiarity with hospital coding and billing processes (preferred). Knowledge of Interqual/Milliman guidelines (preferred).

EPIC EMR

experience (preferred).

Management Experience:

Preferred but not necessary.

Equipment Operated:

PC functions, calculator, general office equipment

SPECIAL REQUIREMENTS

Communication Skills:

Above Average Verbal (Heavy Public Contact) Exceptional Verbal (e.g., Public Speaking) Writing /Composing (Correspondence/Reports)

Other Skills:

Analytical, Mathematics, Medical Terms, P.C.

Work Schedule:

Hybrid Telecommuter Other Requirements:

Requires travel to Harris Health System facilities. Must be able to interact successfully in a culturally diverse environment.