RN Referral Management Coordinator (Virtual) - Prior Authorizations - 40 Hours - Day Shift - HAP Health Alliance Plan
🔍 Troy, Michigan
RN REFERRAL MANAGEMENT COORDINATOR (VIRTUAL) - PRIOR AUTHORIZATIONS - 40 HOURS - DAY SHIFT
Full Time Benefit Eligible
Schedule: Monday through Friday, 8:00AM to 4:30PM, Remote
GENERAL SUMMARY:
Unit Description:
Health Alliance Plan (HAP) is looking to grow our Prior Authorization Team with experienced Registered Nurses! We are a team of Registered Nurses (5 and counting), and Administrative Professionals (3) that review medical necessity and medical criteria for all prior authorizations within our system in partnership with our Medical Director. If you are computer savvy, have a strong work ethic and attention to detail, and are looking to move away from bedside care, this is the team for you!
- Processes referral requests by verifying network assignment, correct provider, applying criteria to determine clinical appropriateness, and assessing level of care requirements.
- Coordinates peer-to-peer conversations with the Medical Director and provider at
the time of the request. - If the Medical Director denies the request, follows denial processing according to the policy. Processes a provider denial letter based on the rationale of the Medical Director at the time of the denial and distributes to the Utilization Management Services staff for processing.
- Reports on potential quality of care issues to the Quality Management Department for further investigation and validation. Tracks physician non-compliance with UM Policies & Procedures and report to QM Department via physician profiling procedures.
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and duties. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described above.
EDUCATION/EXPERIENCE REQUIRED:
- Nursing Diploma, required.
- Bachelor's Degree in Health Care or related field, preferred.
- Minimum of two (2) years of recent clinical management of patients in an inpatient or ambulatory setting, or at least two (2) years of experience in Utilization or Quality Management, required.
CERTIFICATIONS/LICENSURES REQUIRED:
- Registered Nurse (RN) with current Michigan licensure.
Overview
HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, Â Â Â Â Â companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members.
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Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s Â
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Â Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. Â My Choice Rewards is a program as diverse as the people it serves. Â There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. Â As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services. Employee's classified as contingent status are not eligible for benefits
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.