Clinical Denial Specialist

4 days ago

Northridge, California, United States Regal Medical Group Full time
Job Summary

The Denial Nurse will play a critical role in promoting quality and cost-effective medical care by applying clinical acumen and policy guidelines to denials. This position requires a strong understanding of medical management principles and the ability to communicate effectively with various stakeholders.

Key Responsibilities
  • Review denials for appropriateness of care and setting
  • Apply policy guidelines and clinical acumen to denials
  • Process denial letters for affiliated groups
  • Interpret denial language provided by prior authorization nurses, coordinators, and medical directors
  • Translate medical terminology into lay language and grade reading level as appropriate
  • Work closely with coordinators for clinical guidance on denial cases
  • Complete assigned tasks accurately and within specified time limits
  • Maintain smooth working relations with co-workers and supervisors
  • Anticipate future events, set realistic goals, and coordinate activities to ensure smooth workflow and time management
  • Understand and promote medical management principles to facilitate right care at right time in right setting
  • Understand all Regal Medical Management policies and procedures
  • Communicate effectively with department managers, nurses, coordinators, regional medical directors, and staff daily or as indicated regarding all denials processes
  • Speak clearly, concisely, and tactfully on all subjects related to denials
  • Maintain regulatory Turnaround Time Standards per regulatory guidelines
  • Document accurately and completely all necessary information in authorization notes
  • Communicate with prior auth teams and medical directors for denials needing clarification with accurate summary of case and recommendation
  • Demonstrate ability to follow through with requests, sharing of critical information, and getting back to individuals in timely manner
  • Identify denials department needs and report to management for improvement opportunities
Requirements
  • Active California LVN License
  • Minimum of 3+ years of prior authorization/denials experience
  • Minimum of 1+ year of acute care/case management experience
  • Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and PowerPoint)
  • Knowledge of computers, faxes, printers, and all other equipment
  • Ability to deal with responsibility with confidential matters
  • Ability to work in multi-task, high-stress environment
Benefits

Regal Medical Group offers a comprehensive benefits package, including employer-paid comprehensive medical, pharmacy, and dental for employees, vision insurance, zero co-payments for employed physician office visits, flexible spending account, employer-paid life insurance, employee assistance program, behavioral health services, 401(k) retirement savings plan, income protection insurance, and other benefits.

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