Prior authorization rep question

[greygirl81]

I was recently hired by an insurance company as a prior authorization rep for the Medicaid Right Choices Program. Part of that job is to do initial reviews of members to determine over utilization or drug-seeking behaviors. After the initial review a clinician is supposed to do the clinical review. The RN that previously did this no longer works there and now I am am put into this new role. My question is that I am an LPN and the previous employee is telling me I shouldn't be doing this part of the job. I do consult with another RN before any decisions are made about placement in the program. I have read my state nurse practice act and it is very vague. I do not want to be doing something outside of my scope of practice. Advice please!

[mindofmidwifery, ADN]

I was a prior authorization rep and I wasn't a nurse so I don't see why you wouldn't be able to

[Been there,done that, ASN, RN]

Insurance companies know what is required for compliance with Medicaid.

You should have a department devoted to that compliance.

Only your manager knows if you are satisfying the Medicaid requirement for reimbursement.

Ask them.

[yzarcrn, BSN, RN]

If you are following a script/process flow and not making clinical determinations on your own then you are perfectly ok and practicing within your scope of license. Where I work we have staff who are not licensed clinicians approving certain requests. However, they must follow a specific script for that specific request in order to do so. The script goes through many levels to be approved for use. I wouldn't worry about what you are doing.

However, you mention that you "consult" with a nurse before making a decision. Is this in writing? Does this nurse document that he/she reviewed and approved your review? If the answer to that is no, and you do not have something in writing allowing you to do whatever it is you're doing, then beware. The RN could easily say she never reviewed your assessment and signed off on it.

The same rule applies to case management as it does for patient care - if it isn't documented, it wasn't done. Always CYA. I even save emails which provided me instruction to do something that isn't usual practice. This way, if someone ever questions why I did what I did, I can produce the email.