RN Referral Management Coordinator (Virtual) - Prior Authorizations - 40 Hours - Day Shift - HAP Health Alliance Plan

HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members. Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a $6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s major academic medical centers, receiving between $90-$100 million in annual research funding and remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical education and training, the health system has trained nearly 40% of physicians currently practicing in the state and also provides education and training for other health professionals including nurses, pharmacists, radiology and respiratory technicians. visit HenryFord.com.

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.