Prior Authorization Nurse (LVN)

Regal Medical Group•San Bernardino, CA

1d•Onsite

About The Position

The Case Manager Prior Authorization LVN is responsible for supporting the process that manages all outpatient services, including other Prior Authorization Nurses. The goal of the Lead is to actively participate in regular monitoring, auditing and mentoring PANs productivity and clinical reviews. Ensuring that the PAN is following the guidelines in the approval of services or making recommendations for other determinations to the provider/vendor (denial/modification/redirection). Additionally, the goal of the Lead is to model for the PANs proper process and procedure as well as cooperation and support to the other PANs, physician reviewers, Supervisor(s)/Managers(s), and Medical Directors by knowing the process, and working to deliver excellent care based on medical management referral processing guidelines.

Requirements

Graduate of an accredited nursing program
Active California Licensed Vocational Nurse License
At least one year of prior authorization/managed care experience in a leadership role
Knowledge of computers, faxes, printers and all other equipment
Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
Typing 30 WPM with accuracy
Ability to deal with responsibility with confidential matters
Ability to work in a multi-task, high stress environment

Responsibilities

Understand, promote and audit the principles of M. to facilitate the right care at the right time in the right setting.
Communicate effectively and interact with the provider group, staff and health plans daily or as indicated regarding PA and referral authorization issues.
Identify and handle requests that can be approved and brought to resolution based on referral guidelines.
Verify that any new process that is implemented is followed by the PA staff via daily/weekly audits and provided mentoring as needed.
Act as a liaison between Medical Directors and Physician Reviewers to ensure in their queues are processed within standard turnaround times.
Assist the supervisor, manager, Medical Directors and ancillary staff in obtaining additional information and processing difficult or escalated cases.
Participate in the new PAN on boarding process by providing training and shadowing in the different clinical review modules.
Maintain knowledge of all Business Rules and be able to float to provide coverage for vacations and call outs.
Ensure that all referrals are processed within standard turnaround times and review referrals that may fall out of compliance.
Weekly/daily auditing of PAN/PACC production and provide mentoring as
Weekly/daily auditing of PAN/PACC quality and provide mentoring as
Verify that all urgent referrals are processed timely via weekly/daily audits and provide mentoring as needed
Verify that all standard referrals are processed timely via weekly/daily audits and provide mentoring as needed.
All other duties as directed by management.