LVN Pre/Authoriz Nurse Auditor
Harris Health is a nationally recognized health system comprising three teaching hospitals and an extensive network of ambulatory care centers serving the people of Harris County, Texas, since 1966. Staffed by the faculty, fellows and residents from two nationally ranked medical schools, Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth), Harris Health is the first healthcare system in Houston to receive the prestigious National Committee for Quality Assurance (NCQA) designation for its network of patient-centered medical homes.
Each year, Harris Health provides more than 1.8 million total outpatient visits through its more than 40 ambulatory care facilities. Additionally, Harris Health sees more than 177,000 emergency visits at its Level 1 and Level 3 trauma centers and 35,000 hospital admissions through its three hospitals: Ben Taub, LBJ and Quentin Mease.
Established by voter referendum to enhance the level of charity care available in the community, Harris Health System has often received national recognition for serving those in need and for its achievements in operational excellence, such as being named to the 2011, 2012, 2013 and 2014 Most Wired Hospitals lists by the American Hospital Association’s Hospitals & Health Networks magazine.
Additionally, Harris Health System is pleased that each of its three hospitals — Ben Taub, Lyndon B. Johnson and Quentin Mease — achieved Pathway to Excellence™ designation by the American Nurses Credentialing Center.
Skills / Requirements
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 plan's 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.
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
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: Flexible
Other Requirements: Requires travel to Harris Health System facilities. Must be able to interact successfully in a culturally diverse environment.