Supervisor, Prior Authorization ( LVN )

Position Summary:

The Prior Authorization Supervisor (LVN) is responsible for supporting the process that manages all outpatient services, including Prior Authorization Lead Nurses and Review Nurses. The goal of the Clinical Supervisor is to actively participate in regular monitoring, auditing and mentoring PANs productivity and clinical reviews. Ensuring that the PAN is following the guidelines in the approval of services or making recommendations for other determinations to the provider/vendor (denial/modification/redirection). Additionally, the goal of the Prior Authorization Clinical Supervisor is to model for the Nurse Leads, Specialists and PANs proper process and procedure as well as cooperation and support to the other PANs, physician reviewers, Supervisor(s)/Managers(s), and Medical Directors by knowing the process, and working to deliver excellent care based on medical management referral processing guidelines.

Essential Duties and Responsibilities include the following:

• Assists with staff supervision and process to assure the following patient service standard are met by all preauthorization staff.
• Understand all aspects of the functionality of Access Express/Heritage Connect with respect to prior authorization and the customer service modules.
• Understand, promote and support the audit of the principles of UM and facilitate the right care at the right time in the right setting.
• Complete assigned tasks accurately and within specified time limits.
• Anticipate future events, set realistic goals, timetables, coordinate activities to ensure smooth work flow and time management.
• Understand all Regal Medical Management policies and procedures to help create and maintain job aids that are consistent with these policies.
• Communicate effectively and interact with the department managers, compliance officer, regional medical directors and staff daily or as indicated regarding all medical management processes.
• Identify and schedule ongoing training sessions for established staff to review processes with the department trainer where deficiencies appear in audits.
• Verify that patient confidentiality is maintained by the staff and that HIPPAA compliance is observed at all times.
• Speak clearly, concisely and tactfully on all subjects related to Medical Management. Sometimes before large number of people or strangers
• Treat co-workers and customers with patience and respect.
• Arrive to work on time. Consistently be at work. Display flexibility regarding lunches, breaks and work
• Anticipate our provider's needs: Understand their wants and needs, listen for cues and identify how to respond and what level of intervention they need.
• Returns phone calls to providers and follow up with requests.
• Demonstrates honesty and integrity in everyday activities
• Verify that patient confidentiality is maintained by the staff and that HIPPAA compliance is observed at all times.
• Recognizes when an error has been made and immediately correct it then report to appropriate manager.
• Communicates appropriately and clearly to management, co-workers, and physicians.
• Consults other departments as appropriate to provide for an interdisciplinary approach to the patient's needs.
• Treat co-workers and co-workers with patience and respect.
• Maintains quality monitors as assigned by Management.
• Performs other duties as assigned .
• Participates in the efficient, effective, and responsible use of resources such as supplies and equipment.
• Maintain smooth working relations with co-workers and supervisors. Be a “Team Player”.
• Identify trends or issues in the UM process that requires further evaluation for their quality or utilization implications and bring these items to the attention of the UM Manager.
• Communicate effectively and interact with the provider group, staff and health plans daily or as indicated regarding UM and referral authorization issues.
• Maintain organized UM logs and other related information. Identify and handle request that can be approved and brought to resolution.
• Compile auditing data into quarterly progress reports.
• Verify that any new process is communicated to the UM Staff and is followed via monthly audits of the staff's production.
• Update, maintain and approve time sheets Verify that requests for PTO are valid and meet criteria and do not conflict already scheduled dates.
• All other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between $100,000 - $105,000 annually; 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:

• Graduate of an accredited Vocational Nursing Program
• California LVN License in good standing.
• Knowledge of Healthcare and Managed Care required.
• Typing 60 word 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.
• Ability to prioritize
• Ability to meet deadlines