Regal Medical Group is looking for an experienced Clinical Director of Prior Authorization RN to join our team.
The role of the Clinical Director, Prior Authorization RN is to manage the prior authorization nurse case managers and support staff (coordinators), professional claims review nurses and UM compliance staff in order to promote quality, cost effectiveness medical care through strict adherence to all UM policies and procedures within the affiliated medical groups for which this position has oversight.
The Director coordinates, plans and manages staff activities; develops with Medical Director program goals and objectives; makes staff assignments; develops or assists in the development of related prior authorization and claims policy, incorporating current literature and professionally recognized standards; develops or assists in development and implementation of policy and plans for effective patient centered utilization management; together with the medical director, interprets and administers pertinent laws; through direct and indirect contact, evaluates staff and determines the quality of their work efforts; develops and/or implements effective ongoing programs to measure, assess and improve quality of processes and workflows, treatment and services delivered to patients; develops productive work teams; recommends disciplinary actions; collaborates with clinical leadership for educational programs; represents the department in meetings of professional and/or community organizations; compiles data and prepares periodic reports; responsible for coordinating and providing appropriate coverage; maintains contacts with individuals both within and outside of the department who might impact on program activities; assures optimal quality of care and service is provided; participates in Quality Assurance Programs as needed; intervenes in crisis situations and investigates all unusual incidents; leads and participates in meetings; may speak on behalf of department.
This position requires general knowledge of CMS and ICE UM processes/policies/procedures and timeliness standards and management level experience including but not limited to: staff oversight, program management, and issue resolution. Project Management experiences a plus.
A. Essential Duties and Responsibilities include the following:
- Understand, promote and manage with the principles of medical management to facilitate the right care at the right time in the right setting.
- In collaboration with the Medical Director, identifies the need for and participates in the development and implementation of Utilization Management policies and procedures and to promote cost-effectiveness and improved quality.
- Oversee compliance with all health plan, state and federal regulatory requirements (e.g., DMHC, Medicaid, CMS Medicare Part C & D, NCQA where applicable) with respect to prior authorization services, such as turnaround times and appropriate documentation.
- Understand CMS and ICE UM processes/policies/procedures, especially with respect to ICE and CMS denial language and timeliness criteria, with respect to prior authorization services.
- Provide direct supervisory oversight to prior authorization review nurses, professional claims review nurses, UM coordinators and UM compliance staff, including, but not limited to daily work assignments, special project assignments, assistance with performance reviews and disciplinary actions as needed/required.
- Communicate effectively and functions as liaison between nurse and physician reviewers, medical directors, coordinators, PCP and specialist providers, and health plans daily or as indicated regarding any UM or referral authorization issues, as well as care coordination issues.
- Oversight of the professional claims review nurse team (nurses/coders), who work with the claims department to assist in making medical necessity determinations of submitted claims.
- Demonstrates the ability to follow through with requests, sharing of critical information, returning phone calls and getting back to individuals in a timely manner.
- Sets an example for staff by maintaining exemplary compliance and privacy, and reporting compliance and privacy issues and facilitating resolution of others’ issues.
- Assists as necessary in gathering/preparing necessary reports, such as department work-plans, quarterly/semi-annual/annual reports, inter-rater reliability surveys, and plan audits.
- Works with the Utilization Management Committee Chair, and when necessary Medical Management Vice Presidents, Chief Medical Officers or Medical Directors to coordinate activities and Utilization Management Committee meetings.
B. Education and/or Experience:
- Graduate from an accredited Registered Nursing Program with current/active RN license.
- Five years of progressive prior-authorization experience or related experience in a medical group, IPA or management company required, with claims experience recommended.
- Prior experience with project development and implementation, and have excellent organizational, interpersonal and analytical skills.
- Experience supervising staff and monitoring productivity/performance required.
- Must have excellent communications skills both verbally and written.
- Ability to deal with responsibility with confidential matters.
- Must be able to handle multiple projects at one time in a high stress environment, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
- Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics.
- Must have the ability to work with all levels of management and have the ability to develop positive working relationships with health plan auditors and company department heads.
- Must have working knowledge of MS Office environment, and ability to function in highly computerized environment.
- Requires current CA driver’s license and car insurance.
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)
Savings and Retirement:
- 401k Retirement Savings Plan
- Income Protection Insurance
- Paid Time Off (PTO)
- Company celebrations
- Employee Assistance Program
- Employee Referral Bonus
- Business-casual working environment
- Sick days
- Paid holidays
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.