Premier Medical Resources is looking for a Full-Time Clinical Pre-Service Nurse Auditor to join our team!
The Clinical Pre-Service Auditor will provide/confirm precertification of and all authorization requests. The Clinical Pre-Service Auditor will assist with minimizing denials by way of ensuring medical criteria / medical necessity is met prior to services are scheduled. This process includes clinical judgement, utilization management, application, understanding of payor protocols requirements, and verification of medical necessity utilizing nationally recognized criteria.
ESSENTIAL FUNCTIONS:
• 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.
• Performs activities that include obtaining payer authorization for outpatient services that require notification/authorization based on payer specific guidelines.
• Maintains a thorough understanding of the plan's provider contracts, authorization requirements and ongoing follow-up and re-evaluation of clinical departments/areas as requested or needed for authorization review.
• Compiles and maintains established payer protocols to determine the medical appropriateness of ordered pre and post scheduled services.
KNOWLEDGE, SKILLS, AND ABILITIES:
• Familiar with hospital coding and billing processes.
• Knowledge of InterQual/Milliman guidelines, Medicare guidelines
• Above average verbal and written communication skills
• Other Skills: Analytical, Mathematics, Medical Terms
• Must be able to interact successfully in a culturally diverse environment
EDUCATION AND EXPERIENCE:
• Nurse in good standing, currently licensed in the State of Texas without stipulations in practice as a Licensed Vocational Nurse
• Three (3) years of hospital experience in various clinical areas.
• One (1) year utilization review, authorization, or case management experience
BENEFITS:
• 3 Medical Plans
• 2 Dental Plans
• 2 Vision Plans
• Employee Assistant Program
• Short- and Long-Term Disability Insurance
• Accidental Death & Dismemberment Plan
• 401(k) with a 2-year vesting
• PTO + Holidays
Please visit our website for more information:
Premier Medical Resources is a healthcare management company headquartered in Northwest Houston, Texas. At Premier Medical Resources, our goal is to leverage and combine the expertise and skillset of our employees to drive quality in all we do. Our goal is to create career pathways for our employees just starting their professional career, and to those who seek to bring their expertise and leadership as we strive to combine best practices and industry excellence. Come join our team at Premier Medical Resources where passion and career meet.
Compensation to be determined by the education, experience, knowledge, skills, and abilities of the applicant, internal equity, and alignment with market data.
Employment for this position is contingent upon the successful completion of a background check and drug screening.
...support. Serve as first point of contact/escalation for dealers, depots and field personnel to address and resolve issues as it... ...and systems Computer savvy skilled in the use of Microsoft Office with analytical reporting using excel Data analytics extract...
...Representative Key Responsibilities Efficient Call Management: Handle high volumes of... ...and speed, ensuring a positive customer experience. Lead Generation: Identify potential... ...with SAP, Salesforce, and Call Center systems is a strong plus Ability to work...
...the job NO PREVIOUS EXPERIENCE NECESSARY. WE WILL TRAIN THE RIGHT PERSON. This position can be fully remote. Great for the stay-at-home career seeker. All required pre-licensing courses & required state licenses are covered by the company. The desired...
This is for the 2025 - 2026 School Year Compensation package for certified teachers starting at $64,000* Compensation package for non-certified teachers starting at $61,000**Compensation package includes a $5,000 Liberty County Stipend Primary Purpose: ...
...About the Job: Pacific International has been retained by a global airline services provider and market leader undergoing rapid transformation... ...to lead all aspects of operations at its most critical airport site. This flagship location supports the companys most important...