Medical Denial Specialist

4 weeks ago

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

The Denial Nurse is a critical member of our team, responsible for preparing and maintaining health plan criteria for our campus Medical Directors. This role requires collaboration with health plans to obtain updated criteria, ensuring that our staff provides a level of patient services that meets or exceeds our expectations.

Key Responsibilities
  • Assist with preparing and maintaining health plan criteria for the Campus Medical Directors.
  • Collaborate with health plans to obtain updated criteria for each specialty.
  • Ensure that all staff provides a level of patient services that meets or exceeds the organization's expectations.
  • Work collaboratively with Heritage and administration on the health plan template process.
  • Complete assigned tasks accurately and within specified time limits.
  • Maintain smooth working relations with co-workers and supervisors.
  • Anticipate future events, set realistic goals, timetables, coordinate activities to ensure smooth work flow and time management.
  • 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.
Benefits

We offer 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, 401k retirement savings plan, income protection insurance, 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, and mileage.

Requirements
  • Active California Nursing License.
  • At least one year of prior authorization/managed care experience.
  • Typing 60 words per minute 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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