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Banner Health Health Plan LPN Medical Mgmt in Mesa, Arizona

Bring your nursing passion for “making a difference” in people’s lives and making healthcare easier so that life can be better, to us! That is our mission here at Banner-University Health Plans.

As a member of the Prior Authorization Team, you will have the opportunity to work with one of the most cohesive, family like departments in our Health Plan with a very low turnover rate. As a Prior Authorization Nurse, here, at Banner University of Arizona Health Plans, you will have the opportunity to assist our members obtain the highest quality of care, while ensuring it is in the best setting for the member at the right time. We offer an autonomous office environment setting, Monday through Friday 8AM-5pm. The PA department has a culture of “TEAM” that has been established by our Prior Authorization Management team. Each and everyone’s’ role here is needed equally to get the job done!

The Health Plan LPN Medical Management position is located in Mesa, AZ (525 West Brown)

Your pay and benefits (Total Rewards) are important components of your Journey at Banner Health. Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.

About Banner Health Network & Banner Plan Administration

Banner Health Network (BHN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BHN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.

About Banner Health

Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to make health care easier, so life can be better. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee.

Job Summary

Under the direction of the Medical Management Director, Sr Manager and Medical Director, this position is responsible to process health plan medical prior authorization requests, provide case management, care coordination and perform utilization management duties within the appropriate time period as outlined in the BPA and UAHP Medical Management Program Descriptions, and in accordance with all federal and state regulations.

Essential Functions

  • Participates in duties to support prior authorization, concurrent review, and case management within Medical Management. Ensures quality of service and consistent documentation.

  • Performs transfer of accurate, pertinent patient information to support the prior authorization of services, the transition of the patients needs during transitions of care, and perform follow-up discharge calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient related activities in the correct medical record.

  • Works cooperatively with both internal and external customers in assisting members and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.

  • Conducts call rotation for the health plan, as well as departmental call rotation for holidays.

  • Maintains a thorough understanding of accreditation standards and of CMS standards for determination of the medical necessity of services requested.

  • Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes. Identifies issues that may delay patient services and refers to case management, when indicated to facilitate resolution of these issues, pre-service, concurrently and post-service.

  • Maintains a thorough understanding of each plan, including the Evidence of Coverage, authorization requirements, and all applicable federal, state and commercial criteria, such as CMS, AHCCCS, MCG, and Hayes.

  • Performs other related duties as assigned, which are consistent with the goals and qualifications of this position.

Minimum Qualifications

Current, unrestricted Arizona Licensed Practical Nurse (LPN) license permitting work in the State of Arizona. A minimum of three years of experience in an acute care setting. At least two years of experience in prior authorization, utilization management, or case management.

Concurrent and retrospective data management skills are necessary. Working knowledge of medical terminology and coding (ICD-9/10, CPT-4) is required. Computer, data entry and word processing skills, as well as excellent written and verbal communication skills. Must have a working knowledge of care management, prior authorization, hospital and community resources, and utilization management. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format, Must be able to work flexible hours and may need to take rotating call after hours.

Proficient on a computer (PC) with Microsoft Office Products. Ability to work with data bases/programs, and ability to work independently, with analytical, problem solving, decision making.

Preferred Qualifications

Experience specific to Med/Surg, managed care and knowledge of Federal and State programs as well as Commercial plans. Working knowledge of clinical criteria such as MCG (Milliman) or InterQual is preferred.

Additional related education and/or experience preferred.

Job Number 253192

Facility Banner Plan Administration Inc

Department Prior Authorization

Address : Street 525 West Brown Rd

Address : Location US-AZ-Mesa

Work Schedule Day

Position Type FT: Full-Time

Posting Category Nursing - LPN