Job Description

The Clinical Nurse Project Manager role will promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to denials. This role will review for appropriate care and setting, and follow guidelines/policies as they relate to the review process . This role will be responsible for processing denial letters for all affiliated groups, interpreting denial language provided by the prior authorization nurse, coordinators, and medical directors, and placing it into the appropriate templates while translating medical terminology into lay language and grading the reading level as appropriate. They will work closely with the coordinators in the department for clinical guidance on denial cases.

Essential Duties and Responsibilities include the following:

• Understand all aspects of the functionality of Access Express concerning prior authorization and the denials
• Complete assigned tasks accurately and within specified time limits
• Maintain smooth working relations with co-workers and supervisors, be a “Team Player”
• Anticipate future events, set realistic goals, timetables, and coordinate activities to ensure smooth workflow and time management
• Understand, promote, and review the principles of medical management to facilitate the right care at the right time in the right setting
• Understand all Regal Medical Management policies and procedures
• Communicate effectively and interact with the department managers, nurses, coordinators, regional medical directors, and staff daily or as indicated regarding all denials processes
• Speak concisely and tactfully on all subjects related to Denials
• Maintain a working relationship with denials coordinators, the prior auth teams, the pharmacy team, the medical directors, and the network management
• When necessary, act as liaison between the prior auth coordinators, prior auth nurses, and medical directors
• Maintain regulatory Turnaround Time Standards per regulatory guidelines
• Document accurately and completely all necessary information in authorization notes
• Communicating with the prior auth teams and medical directors for those denials needing clarification, with an accurate summary of the case and recommendation
• Demonstrates the ability to follow through with requests, share critical information, and get back to individuals promptly.
• Identifies the department's needs and reports to management for improvement opportunities
• All other duties as directed by management

Organizational Responsibilities:

• Proactively support and practice the company's mission, vision, and values.
• Follow Employee Handbook guidelines and company policies, and procedures.
• Follow the established departmental dress code.
• Appropriately and accurately maintain timekeeping records.
• Adhere to the attendance policy and time off requests.
• Follow safety policies and procedures.
• Be flexible and adaptable, and courteous, and promote professionalism.
• Communicate verbally and in writing through appropriate channels.
• Maintain confidentiality at all times in compliance with company policy and HIPAA requirements.
• The employee has completed all required annual Compliance training and signed the attestation form is attached for each module.

Education and/or Experience:

• Active California LVN Or RN License
• Minimum of 3+ years of prior authorization/ denials experience
• Minimum of 1+ year of acute care/case management experience
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and PowerPoint)
• Knowledge of computers, faxes, printers, and all other equipment
• Ability to deal with responsibility in confidential matters
• Ability to work in a multi-tasking, high-stress environment

The pay range for this position at commencement of employment is expected to be up $104,000 annually, dependent on licensure; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, the 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 employees
• Vision insurance
• Zero co-payments for employed physicians office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401 (k) Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employers will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Qualifications

Education and/or Experience:

• Active California LVN Or RN License
• Minimum of 3+ year of prior authorization/ denials experience
• Minimum of 1+ year of acute care/case management experience
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Knowledge of computers, faxes, printers and all other equipment
• Ability to deal with responsibility with confidential matters
• Ability to work in a multi-task, high stress environment