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.
Additional Details
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 functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers.
Benefits
The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health 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.