Supervisor, Denials Nurse ( LVN )

Regal Medical Group • Los Angeles, CA

118d • $100,000 - $105,000

About The Position

The Prior Authorization Supervisor (LVN) is responsible for supporting the process that manages all outpatient services, including Prior Authorization Lead Nurses and Review Nurses. The goal of the Clinical Supervisor 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 Prior Authorization Clinical Supervisor is to model for the Nurse Leads, Specialists and 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 Vocational Nursing Program.
• California LVN License in good standing.
• Knowledge of Healthcare and Managed Care required.
• Typing 60 word per minutes 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.
• Ability to prioritize.
• Ability to meet deadlines.

Responsibilities

• Assists with staff supervision and process to assure the following patient service standard are met by all preauthorization staff.
• Understand all aspects of the functionality of Access Express/Heritage Connect with respect to prior authorization and the customer service modules.
• Understand, promote and support the audit of the principles of UM and facilitate the right care at the right time in the right setting.
• Complete assigned tasks accurately and within specified time limits.
• Anticipate future events, set realistic goals, timetables, coordinate activities to ensure smooth work flow and time management.
• Understand all Regal Medical Management policies and procedures to help create and maintain job aids that are consistent with these policies.
• 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.
• 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.
• Treat co-workers and customers with patience and respect.
• Arrive to work on time. Consistently be at work. Display flexibility regarding lunches, breaks and work.
• Anticipate our provider’s needs: Understand their wants and needs, listen for cues and identify how to respond and what level of intervention they need.
• Returns phone calls to providers and follow up with requests.
• Demonstrates honesty and integrity in everyday activities.
• Recognizes when an error has been made and immediately correct it then report to appropriate manager.
• Consults other departments as appropriate to provide for an interdisciplinary approach to the patient’s needs.
• Maintains quality monitors as assigned by Management.
• Performs other duties as assigned.
• Participates in the efficient, effective, and responsible use of resources such as supplies and equipment.
• Maintain smooth working relations with co-workers and supervisors. Be a 'Team Player'.
• Identify trends or issues in the UM process that requires further evaluation for their quality or utilization implications and bring these items to the attention of the UM Manager.
• Communicate effectively and interact with the provider group, staff and health plans daily or as indicated regarding UM and referral authorization issues.
• Maintain organized UM logs and other related information. Identify and handle request that can be approved and brought to resolution.
• Compile auditing data into quarterly progress reports.
• Verify that any new process is communicated to the UM Staff and is followed via monthly audits of the staff’s production.
• Update, maintain and approve time sheets Verify that requests for PTO are valid and meet criteria and do not conflict already scheduled dates.

Benefits

• Employer-paid comprehensive medical, pharmacy, and dental for employees.
• Vision insurance.
• Zero co-payments for employed physician office visits.
• Flexible Spending Account (FSA).
• Employer-Paid Life Insurance.
• Employee Assistance Program (EAP).
• Behavioral Health Services.
• 401k Retirement Savings Plan.
• Income Protection Insurance.
• Vacation Time.
• Company celebrations.
• Employee Referral Bonus.
• Tuition Reimbursement.
• License Renewal CEU Cost Reimbursement Program.
• Business-casual working environment.
• Sick days.
• Paid holidays.
• Mileage.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees