layiq

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Registered Nurse II - Prior Authorization and Referral at Texas A&M University System | LAYIQ

Prior Authorizations & Care Coordination
Reviews and processes prior authorizations for medications, radiology procedures, and specialty services.
Navigates payer policies including step therapy protocols, quantity limits, preferred drug lists, and therapeutic substitutions.
Assists patients and providers in identifying and applying for patient assistance programs or financial assistance when available.
Facilitate peer-to-peer reviews with payers when pre-authorizations are denied.
Collaborate with providers to gather necessary clinical documentation and address denials or escalations.
Tracks status of authorizations and manages related communications with patients and staff.
Referral Management
Coordinates external referrals to specialty providers, ensuring completeness of documentation and timely submission.
Follow up with external offices, providers, and students to support continuity of care.
Maintains accurate tracking and communication regarding referral outcomes.
Staff Supervision and Leadership
Supervises designated nursing or medical support staff by managing workload distribution, scheduling, and coverage planning.
Reviews and approves time sheets, time off requests, and ensures coverage meets operational needs.
Provides coaching and timely feedback to support employee development and professional growth.
Participates in performance evaluations alongside the nursing leadership.
Patient Care and Education
Educates patients on referral processes, coverage details, and treatment plans.
Documents clinical and administrative activities in the electronic medical record.
Clinical Operations
Supports day-to-day operations in the clinic, assists in scheduling and patient flow.
Helps ensure compliance with healthcare regulations and university policies.
Assists with the implementation of clinic policies, standards, and procedural updates.
Resourcing and Quality Improvement
Serves as a resource for nursing and administrative staff on prior authorization and referral policies.
Participates in the development and implementation of workflow improvements related to access and coordination of care.
Participates in onboarding and training of new staff, ensuring orientation to clinic protocols and standards.
Represents the nursing team in interdisciplinary meetings or process improvement groups, as needed.

Bachelor's degree in Nursing.
Two years of experience as a Registered Nurse, within the last ten years, including experience in at least one of the following areas:
Prior authorizations or utilization management
Care coordination or case management
Insurance or payer policy navigation
Outpatient clinic operations or referral processing
Reviewing medical documentation for insurance or compliance purposes
Working in a college health, primary care, or ambulatory care setting
Experience spanning multiple areas listed above (e.g., combining prior authorizations with outside medication management, clinic operations, or care coordination).
Experience with direct supervision of employees, performance evaluations, staffing, and/or scheduling.
Knowledge, Skills, and Abilities: Knowledge of standard nursing procedures and techniques.
Strong understanding of insurance guidelines and prior authorization processes.
Ability to review and interpret clinical documentation to determine what is required for prior authorizations and referrals.
High level of comfort with computers, databases, and web-based systems; able to independently navigate payer portals, referral platforms, and electronic records systems.
Excellent organizational, communication, and problem-solving skills.
Ability to multitask and work cooperatively with others.
Ability to handle sensitive information and maintain confidentiality.
Proficiency in documenting and navigating electronic medical records.
Other Requirements and Factors
The individual in this position may be required to handle Personally Identifiable Information 1 (PII) as defined by Family Educational Rights and Privacy Act (FERPA) regulations and Protected Health Information 2 (PHI) as defined by Health Insurance Portability and Accountability Act (HIPAA) regulations. The individual is required to handle PII and PHI in accordance with University Health Services (UHS), Texas A&M University System policies, and all applicable federal regulations.
1PII includes information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other personal or identifying information.
2PHI refers to any health information that can be linked to a specific individual and is protected under federal privacy regulations.
FERPA and HIPAA training are required upon employment and must be completed on a recurring basis as determined by policy and job duties.
Why Texas A&M University?

Registered Nurse II - Prior Authorization and Referral

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