Job Description

The Clinical Nurse Reviewer is focus 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.

Essential Duties and Responsibilities include the following:

1. 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.
2. Performs departmental and program-specific audits and analyses related to records review and clinical practices
3. Manages audit reports and CAP responses
4. Collaborate with existing inpatient team to ensure proper implementation of UM process in compliance with the Policy and Procedure.
5. Identify opportunities for the development and implementation of new approaches that improve efficiencies and production while maintaining quality
6. 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.
7. 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.
8. Identify errors on authorization in a timely manner and sends findings to IP and TT leadership for timely correction.
9. 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.
10. Effectively review authorizations to ensure that it follows compliance requirement as identified in our Policy and procedure.
11. Collaboration with clinical team to ensure synchronization of sub-areas' operations to reach organizational goals set forth by the department.
12. Maintaining and updating the appropriate databases and department tools with current information.
13. Ensure contract compliance and adherence to DMHC, DHS, CMS and other regulatory agencies as required by company policy and contracting HMOs.
14. Oversight of database maintenance and accuracy through use of audits.
15. Ensure accurate and timely data reporting requirements are being met Know and follow the Employee Handbook policies and procedures.
16. Maintain patient confidentiality so that HIPPAA compliance is observed at all times.
17. All other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between RN's $45 - $50 per hour; 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 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

Savings and Retirement:

401k 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

Employer 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:

• 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.
• Knowledge of contracting principles/tools. (preferred)
• Excellent verbal and written communication skills.
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Must be able to travel within service area and have valid driver’s license and insurance (preferred)