Position Summary:

The Clinical Nurse Reviewer is responsible for reviewing authorizations in the medical director queue. The goal of the Clinical Nurse Reviewer is to maintain regulatory turn around times, ensure correct guidelines are utilized for the request, and appropriately steer the requests to utilized network providers and appropriate place of service (where applicable). This position helps maintain appropriate utilization and to support the network providers, all with an eye on quality patient care.

Essential Duties and Responsibilities include the following:

• The goal of the Clinical Nurse Reviewer is to effectively review prior authorizations, providing updated criteria and necessity, utilizing the appropriate tools and reviewing diagnostics.
• Identifying the appropriate facilities in order to provide the highest level of care, in the most efficient manner, while utilizing only the resources necessary for that episode of care.
• Apply medical necessity guidelines to prior authorization requests.
• Maintain regulatory turn around times.
• Understand the appropriate use of community (versus tertiary) providers capable of providing necessary patient care in the correct setting.
• Review initial consultation requests with the understanding of anticipated procedures, procedure location, and lengths of stay based on provider trends.
• Communicate with provider offices in order to educate and reinforce utilization and correct network providers.
• Work with MD prior authorization team and other campus leadership to discuss noted trends within the provider network from a UM perspective.
• Continues to maintain a positive and collaborative relationship with all internal departments, becoming a source of valuable information and providing assistance with authorizations as necessary.
• Anticipate our customer needs: Understand the wants and needs of customers, listen for cues and identify how to respond and what level of intervention they need.
• Refrains from discussing personal business in front of the customer or speak a foreign language different from the customer's language.
• Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
• Protects privacy for both patients and employees; ensures all personal health information is kept confidential i.e., (sensitive papers, charts, and reports are not in view of the public).
• 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.

The pay range for this position at commencement of employment is expected to be between$45.00-50.00/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.

Education and/or Experience:

• High school graduate required; Nursing degree required.
• 2+ yrs of Healthcare and Managed Care preferred.
• Typing 60 words 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.