Reviewer, Clinical RN

Regal Medical Group•Los Angeles, CA

3d•Hybrid

About The Position

The Clinical Nurse Reviewer is focused on auditing the IP UM process and identifying process improvement measures to assist in meeting regulatory requirements and maintaining compliance with the organization’s Policies and procedures. The position will work collaboratively with the IP leadership team to streamline processes and support optimal medical management and clinical service delivery for members. This position will also track and trend progress of the IP team on responding to errors, CAPS and improvement measures.

Requirements

Graduate from an accredited Registered Nursing (RN) program.
Current California license
Minimum of 2 years relevant work experience in a managed care setting, health plan, or large medical group administration.
Knowledge of the prior authorization process.
Excellent verbal and written communication skills.
Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)

Nice To Haves

Knowledge of contracting principles/tools.
Must be able to travel within service area and have valid driver’s license and insurance

Responsibilities

The Clinical Nurse Reviewer will specifically run analysis on the different reports in Inpatient Case Management and report findings to Senior Director of Regulatory Compliance and VP of Clinical operations.
Performs departmental and program-specific audits and analyses related to records review and clinical practices
Manages audit reports and CAP responses
Collaborate with existing inpatient team to ensure proper implementation of UM process in compliance with the Policy and Procedure.
Identify opportunities for the development and implementation of new approaches that improve efficiencies and production while maintaining quality
Work in collaboration with the Senior Director of Regulatory Compliance and Support and leadership team to thoroughly review different authorizations done in IP Case Management.
Serve as front line support to the Inpatient and Transfer Team staff in aligning daily UM activities with current process according to Policies and Procedures.
Identify errors on authorization in a timely manner and sends findings to IP and TT leadership for timely correction.
Together with the Senior Director of Regulatory support and compliance, assesses and develops a plan to address recurring errors in report and issue Corrective Action Plan to appropriate team as needed.
Effectively review authorizations to ensure that it follows compliance requirement as identified in our Policy and procedure.
Collaboration with clinical team to ensure synchronization of sub-areas' operations to reach organizational goals set forth by the department.
Maintaining and updating the appropriate databases and department tools with current information.
Ensure contract compliance and adherence to DMHC, DHS, CMS and other regulatory agencies as required by company policy and contracting HMOs.
Oversight of database maintenance and accuracy through use of audits.
Ensure accurate and timely data reporting requirements are being met Know and follow the Employee Handbook policies and procedures.
Maintain patient confidentiality so that HIPPAA compliance is observed at all times.
All other duties as directed by management.