Prior Authorization Nurse

The Prior Authorization Review Nurse is responsible for supporting the process that manages all outpatient services. The goal of the Prior Authorization Review Nurse is to actively participate in the review of, current services being rendered and requests for service, and to follow guidelines in the approval of those services or making recommendations for other determinations to the provider reviewer in the most cost effective manner, and ensures the optimum quality of care is provided.Essential Duties and Responsibilities include the following:Plan, research alternative and assist in the routing of member to the most appropriate IPA provider (s), ancillary providers and sites of care.Act as liaison between the case managers, UM coordinators, contracted providers, and the members. patients, providers, and other healthcare providers.Perform case reviews base on key screening outpatient indicators and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to community standards and health plan/ CMS guidelines.Collaborate and communicate with all the members of health care team to coordinate the. continuum of care by devising plans for the identification of member cases incorporating inpatient and post hospitalization care.Prepare, evaluate and report on utilization data, outcome measurement and quality an issue, based on information's received from case review to QI supervisor.Maintain regulatory Turnaround Time Standards per CMS (Senior) and ICE (Commercial).Documents accurately and completely necessary information in authorization notes.Submit authorization requests needing physician review with an accurate interpretation and recommendation.Accurately and timely evaluates all monthly rental equipment for continued need and requests pick-up of any unnecessary equipment immediately.Effectively manages the rental and purchase of all DME to assure the appropriate use of rental vs. purchase.Coordinates and insures appropriate utilization of ancillary professional services, i.e. (Nurse visits, PT,OT, speech, and home based services)Maintain patient confidentiality so that HIPAA compliance is observed at all timesAssists other staff and supports the team approach.Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.Demonstrates honesty and integrity in every day activities.Recognizes when an error has been made and immediately reports to appropriate manager.Participates in "service recovery" through follow-up with an upset customer, gathering information, and demonstrates empathy.Identify network needs and report to management for potential contracting opportunities.Maintains quality monitors as assigned by Supervisor.Participates in orientation, instruction/training of new personnel.Participates in the efficient, effective, and responsible use of resources such as supplies and equipment.Know and follow the Employee Handbook polices and proceduresPerforms other duties as assigned.Education RequirementsGraduate from an accredited Nursing ProgramCurrent California Nursing LicenseCurrent CPR Certification.Minimum of 1 year acute experienceKnowledge of Healthcare and Managed Care preferred.Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization and Quality Management.Knowledgeable with the pre authorization process and flow.Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).Ability to deal with responsibility with confidential mattersAbility to work in a multi-task, high stress environmentThe pay range for this position at commencement of employment is expected to be between $37.50/hour - $40/hour for LVNs and $45/hour-$50/hour for RNs however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.Details of participation in these benefit plans will be provided if an employee receives an offer of employment.If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.Full Time Position Benefits:The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.Health and Wellness:Employer-paid comprehensive medical, pharmacy, and dental for employeesVision insuranceZero co-payments for employed physician office visitsFlexible Spending Account (FSA)Employer-Paid Life InsuranceEmployee Assistance Program (EAP)Behavioral Health ServicesSavings and Retirement:401k Retirement Savings PlanIncome Protection InsuranceOther Benefits:Vacation TimeCompany celebrationsEmployee Assistance ProgramEmployee Referral BonusTuition ReimbursementLicense Renewal CEU Cost Reimbursement ProgramBusiness-casual working environmentSick daysPaid holidaysMileageEducation and/or Experience:Graduate from an accredited Nursing ProgramCurrent California LicensesCurrent CPR Certification.Minimum of 1 year acute experienceKnowledge of Healthcare and Managed Care preferred.Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization and Quality Management.Knowledgeable with the pre authorization process and flow.Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).Ability to deal with responsibility with confidential mattersAbility to work in a multi-task, high stress environment.