- Location
- Logan Health Medical Center, United States of America
- Workplace
- Remote
- Type
- Full-time
- Department
- Healthcare
- Education
- Bachelor
- Source
- Workday
Description
Our Mission: Quality, compassionate care for all.
Our Vision: Reimagine health care through connection, service and innovation.
Our Core Values: Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.
Logan Health is looking for an experienced RN to take on the role of Clinical Authorization Specialist!
This position will focus on prior authorization and denials management for imaging services across inpatient and outpatient settings.
What you'll do:
You'll partner with clinic leadership, providers, nursing staff, and other interdisciplinary team members to support medical necessity reviews, prior authorization requests, and payer denial management for assigned services and treatments. Utilizing clinical expertise, this position evaluates documentation, identifies authorization requirements, facilitates appeals, and collaborates with payers to obtain coverage approvals while minimizing delays in patient care. The position serves as a resource regarding payer guidelines and medical necessity criteria, ensuring accurate documentation, timely communication of authorization outcomes, and supporting optimal patient access to care.
Location:
This unique hybrid position will work approximately four days remotely and one day on site at Logan Health Medical Center in Kalispell, MT.
- Applicants must reside in the Flathead Valley area as you will be meeting weekly on site with clinical staff, UM Specialists, and providers on initiatives and provide education.
Qualifications:
Current Montana RN license or multistate compact license with authorization to practice nursing in Montana.
Associate Degree in Nursing required; Bachelor of Science in Nursing preferred.
Minimum three (3) years of clinical nursing experience in acute care, ambulatory, specialty clinic, infusion, oncology, case management, utilization management, care coordination, or a related healthcare setting.
Knowledge of medical terminology, clinical documentation, diagnostic testing, treatment planning, and healthcare reimbursement processes.
Strong understanding of medical necessity criteria and payer authorization requirements.
Promotes excellence through setting high standards and providing high quality outcomes.
Ability to act with integrity, kindness, and exhibit empathy.
Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.
Commitment to working in a team environment and maintaining confidentiality as needed.
Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.
Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and ability to learn other software as needed.
Job Specific Duties:
Partners with providers, clinic staff, and interdisciplinary teams to facilitate prior authorizations and support medical necessity requirements for assigned services and treatments.
Reviews medical records and clinical documentation to ensure submissions meet payer requirements and support medical necessity review and determinations.
Submits prior authorization, pre-certification, and medical necessity requests to commercial, Medicare, Medicaid, and other third-party payers.
Researches and interprets payer policies, coverage guidelines, and authorization requirements to facilitate timely approval of services.
Monitors authorization requests, tracks outcomes, and proactively follows up on pending, delayed, or incomplete determinations.
Collaborates with providers and clinical staff to obtain additional documentation required to support authorization requests, reconsiderations, and appeals.
Reviews authorization denials, identifies opportunities for appeal, and coordinates the submission of supporting clinical documentation for reconsideration.
Communicates authorization status, payer requirements, approvals, and denial outcomes to providers, clinic staff, and other stakeholders in a timely manner.
Accurately documents authorization activities, payer communications, determinations, and appeal outcomes within the electronic health record and applicable tracking systems.
Serves as a clinical resource regarding payer regulations, medical necessity criteria, authorization processes, and denial management while supporting quality improvement initiatives and regulatory compliance.
The above essential functions are representative of major duties of positions in this job classification. Specific duties and responsibilities may vary based upon departmental needs. Other duties may be assigned similar to the above consistent with knowledge, skills and abilities required for the job. Not all of the duties may be assigned to a position.
Maintains regular and consistent attendance as scheduled by department leadership.
Shift:
Day Shift - 8 Hours (United States of America)Schedule: Full-time, 40 hours per week, 8-hour day shifts
Logan Health operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.
Notice of Pre-Employment Screening Requirements
If you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes:
Criminal background check
Reference checks
Drug Screening
Health and Immunizations Screening
Physical Demand Review/Screening
Equal Opportunity Employer
Logan Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability). We encourage all qualified individuals to apply for employment. We do not discriminate against any applicant or employee based on protected veteran status, race, color, gender, sexual orientation, religion, national origin, age, disability or any other basis protected by applicable law. If you require accommodation to complete the application, testing or interview process, please notify Human Resources.