DENIAL NURSE
4 weeks ago
Position Summary:
The Denial Nurse is responsible for being the second line resource for preparing and maintaining health plan criteria for the campus Medical Directors. This includes collaborating with each Health Plan to obtain updated/adequate criteria for each specialty to ensure that appropriate criteria are referenced upon furnishing a denial. This includes questions regarding procedures, training, and processes to assure compliance with RMG/LMG policies and procedures. The Denial Nurse assists the campus Regional Medical Directors and Inpatient Manager/Supervisor with daily operations and management of denials, training, auditing functions, and assuring that all staff provides a level of patient services that meets or exceeds the organization's expectations. Denial nurse will work collaboratively with Heritage and administration on the health plan template process.
Essential Duties and Responsibilities include the following:
- Assists with preparing and maintaining health plan criteria for the Campus Medical Directors.
- Understand all aspects of the functionality of Access Express/Heritage Connect with respect to prior authorization and the customer service modules.
- Complete assigned tasks accurately and within specified time limits.
- Maintain smooth working relations with co-workers and supervisors. Be a Team Player.
- Anticipate future events, set realistic goals, timetables, coordinate activities to ensure smooth work flow and time management.
- Understand all Regal Medical Management policies and procedures to help create and maintain job aids that are consistent with these policies.
- Communicate effectively and interact with the department managers, compliance officer, regional medical directors and staff daily or as indicated regarding all medical management processes.
- Identify and schedule ongoing training sessions for established staff to review processes with the department trainer where deficiencies appear in audits.
- Help to train new nurses, physicians, medical directors, and necessary staff to rapidly learn the Organizations principles of Medical Management and to facilitate the right care at the right time in the right setting.
- Verify that patient confidentiality is maintained by the staff and that HIPPAA compliance is observed at all times.
- Speak clearly, concisely and tactfully on all subjects related to Medical Management.
The pay range for this position at commencement of employment is expected to be between LVN's $37.50 - $40 or for RN's $45 - $50 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an at-will position and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:
- Employer-paid comprehensive medical, pharmacy, and dental for employees
- Vision insurance
- Zero co-payments for employed physician office visits
- Flexible Spending Account (FSA)
- Employer-Paid Life Insurance
- Employee Assistance Program (EAP)
- Behavioral Health Services
Savings and Retirement:
- 401k Retirement Savings Plan
- Income Protection Insurance
Other Benefits:
- Vacation Time
- Company celebrations
- Employee Assistance Program
- Employee Referral Bonus
- Tuition Reimbursement
- License Renewal CEU Cost Reimbursement Program
- Business-casual working environment
- Sick days
- Paid holidays
- Mileage
Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.
Requirements
Education and / or Experience:
- Active California Nursing License.
- At least one year of prior authorization/ managed care experience.
- Typing 60 words per minutes with accuracy.
- Knowledge of computers, faxes, printers and all other equipment.
- Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
- Ability to deal with responsibility with confidential matters.
- Ability to work in a multi-task, high stress environment.
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