Referral Nurse
1 month ago
**What You Will Be Doing**:
- 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.
**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.
- 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 the principles and practices of managed care
**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._
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