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Spectrum Health Authorization Nurse Coordinator, LPN (Priority Health) in GRAND RAPIDS, Michigan

Position SummaryThis position is responsible for making decisions on authorization requests. Decisions will be made by utilizing clinical expertise, reviewing medical documentation, determining need, considering alternatives, and according to Medical Policy, Interqual Criteria, Medicare Guidelines, and plan documents. Case presentation will be made to medical director for all complex requests and when medical criteria is not met for final determination.spanEssential Job Functions:/spanul type="disc"lispanMeet daily productivity standards of case review /span/lilispanProvide a clear case presentation to the medical director /span/lilispanPrecise creation of Letters and Language associated with Authorization Requests /span/lilispanProvide quality clinical reviews of medical documentation /span/lilispanAppropriate application of Medical Policies and InterQual Criteria /span/lilispanCoordinating with healthcare providers to gain necessary information /span/lilispanAccurately enterand#160;data into complex computer systems for claims payment and reporting /span/lilispanCoordinateand#160;the peer to peer process with the physician or physician advisor /span/lilispanComplyand#160;with HIPAA/CMS regulations and the department policies and procedures/span/li/ul Basic Qualifications: Education - High School Diploma or equivalent Experience - 5 years of relevant experience in A minimum of 5 years clinical experience Licenses - Licensed Practical Nurse in MI (LPN) Health Management Preferred Qualifications: Experience - 1 year of relevant experience in One year previous physician office experience 1 year of relevant experience in One year previous insurance authorization experience

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