Nurse Supervisor, Utilization Management DCU

Regal Medical Group•Los Angeles, CA

13d•$105,000 - $120,000

About The Position

The Clinical Supervisor, UM Denial Compliance assures a high quality, efficient, timely and compliant denial process. Responsible to assure compliance with all applicable regulatory, accreditation and health plan requirements for Regal Medical Group, Lakeside Medical Group, and ADOC.

Requirements

Graduate from an accredited Registered Nursing Program with current/active license. RN preferred.
Five years of progressive prior-authorization, appeals & grievance, health plan oversight or health plan compliance related experience in a health plan, medical group, IPA or management company required.
Prior experience with project development and implementation, and have excellent organizational, interpersonal and analytical skills.
Experience supervising staff and monitoring productivity/performance required. Experience with production environment preferred.
Must have excellent communications skills both verbally and written.
Ability to deal with responsibility with confidential matters.
Must be able to handle multiple projects at one time in a high stress environment, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics.
Must have the ability to work with all levels of management and have the ability to develop positive working relationships with health plan auditors and company department heads.
Must have working knowledge of MS Office environment, and ability to function in highly computerized environment.
Requires current CA driver’s license and car insurance.

Responsibilities

Provide direct supervision to licensed and non-licensed denial unit staff, including, but not limited to daily work assignments, special project assignments, performance reviews and disciplinary actions as needed/required.
Communicates effectively and collaborates with physician reviewers, medical directors, prior authorization teams, delegation oversight and other departments.
Demonstrates the ability to follow through with requests, sharing of critical information, returning phone calls and getting back to individuals in a timely manner.
Sets an example for staff by maintaining compliance and privacy, and reporting compliance and privacy issues and facilitating resolution of others’ issues.
Assists as necessary in gathering/preparing necessary reports, such as department work-plans, quarterly/semi-annual/annual reports, inter-rater reliability surveys, and plan audits.
Conducts internal quality monitoring for denial process.
Develops and presents educational sessions for denial unit staff, medical directors and prior auth nurses to assure high quality compliant denial correspondence.
Ensures compliance with regulatory, accreditation and delegated health plan requirements related to the denial process.
Manages daily departmental functions including inventory management, turn-around-time compliance, reporting, staffing and supervision.
Communicate effectively between nurse and physician reviewers, medical directors, and coordinators daily or as indicated regarding any denial issues.
Assesses Medical Groups compliance with the regulatory and quality measures and develops strategies for improvement within the denial unit scope.
Reviews reports, audit findings, appeal overturn data from Health Plans or other sources regarding group’s performance; identifies deficiencies, and develops and implements correction action plans and reassessment.
Regularly reports departmental performance to leadership.
Motivates, educates and provides assistance to staff.
Stays abreast of state and federal regulations, standards, and reporting requirements as it relates to the department.
Determines impact of implementation of new regulations and statutes and required notifications, changes, and training as it relates to the department.
Communicates required changes, develops procedures, job aids, tools to assess risks, and leverages existing processes to facilitate required changes.
In conjunction with direction, develops department objectives. Leads department to achievement of objectives.
Provides professional/technical guidance to team members and stakeholders.
Implements work processes and procedures to assure compliance with company policy.
Influences others regarding existing concepts, processes and/or methodology.
All other duties as directed by management