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Referral Nurse
2 months ago
What You Will Be Doing:
Under general supervision, responsible for applying medical necessity criteria and processing authorization requests.
- Reviews and verifies authorizations and supporting documentation for accuracy and completeness, including but not limited to eligibility, codes and clinical notes.
- Obtains required documentation and information from a variety of internal and external sources.
- Determines if request meets established medical guidelines, and approves, defers or escalates to Medical Director for review.
- Monitors deferrals and escalated requests to ensure timely responses.
- Prepares communications, including denial, approved with modifications and deferral letters using standard templates; submits for approval and distributes.
REMOTE. MUST RESIDE IN CALIFORNIA.
What You Bring:
Required
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Strong clinical skills as defined in California scope of practice guidelines for LVN’s and/or RN's.
- Strong knowledge of and proficient skills in administering protocols.
- Ability to read and apply clinical information, practice guidelines and other complex data and information.
- Strong assessment and analytical skills, with ability to determine key issues, develop effective action plans and implement to successful conclusion.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong oral and written communication skills, with the ability to communicate professionally to diverse individuals, effectively explain complex information and document according to standards.
- Strong listening skills, with the ability to accurately receive and understand messages.
- Strong conflict resolution skills, including but not limited to the ability to use tact and diplomacy to diffuse emotional situations.
- Ability to work independently and as part of a team.
- Demonstrated commitment to HPSJ’s strategy, vision, mission and values.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Basic problem solving and analytical skills, including the ability to perform routine analysis and solve problems using identified data and information.
- Basic skills in Windows, Word, Excel and Outlook.
- Ability to enter data into and navigate through multiple databases.
- Basic arithmetic skills.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion
Preferred
- Knowledge of NCQA standards as they apply to authorizations and referrals.
- Knowledge of the principles and practices of managed care
- Knowledge of Medi-Cal and/or Medicare regulations as they apply to authorizations and referrals
What you Have:
Education and Experience
Required
- Graduation from an accredited nursing school; and
- At least one year of clinical experience.
Preferred
- Bachelor’s Degree
Licensure, Certification, Registration
Required
- Unrestricted California Vocational Nurse license; OR
- Unrestricted California Registered Nurse license
What You Will Get:
HPSJ Perks:
- Competitive salary
- Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
- Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
- CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
- Two flexible spending accounts (FSAs)
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Life Assistance Program
- Health Advocacy
- Supplemental medical, legal, identity theft protection
- Access to exclusive discount mall
- Education and training reimbursement in addition to employer-paid elective learning courses.
- A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
- A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
- Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
Our Vision:
Continuously improve the health of our community.
Our Mission:
We provide healthcare value and advance wellness through community partnerships.
We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.
