RN, Referrals Manager

Description

Oversees and directs the daily operations of the complete prior authorization process, including; validation of accurate ICD, CPT and HCPC codes, hierarchy of Health Plan and CMS criteria for clinical review and UM approvals, Medical Director determinations and provider/member letter notifications.

Professional Duties

Provides daily oversight of all personnel with the Referral Dept, ensuring all regulatory requirements are met. Additionally keeps up to date with all HPN, DOHC Polices & Procedures and develops appropriate job aids to assist the staff.
Oversee and manage in departmental training and orientation of new employees.
Collaborates closely with Senior Medical Director, Senior Director and Senior Coordinators to ensure all turn-round times are met, proper documentation is performed, appropriate criteria pulled, correct templates are used and files are processed timely/correctly. Tracks and trends data to fix a problem before it impacts our reporting or audits.
Provides expert knowledge to other departments and their staff regarding contracts, processing, benefits and criteria. Additionally, is the main contact for any IPA or Health Plan inquiries.
Performs ongoing monitoring and analytic review of productivity followed by any appropriate coaching or in-service to the Team.
Serves as the primary clinical resource for the department, as well as any offshore Vendors used in the processing of the referrals.
Participates in CMS, DMHC, DHCS, and Health Plan audits. Works closely with Senior Direct to complete root cause analysis and Corrective Action Plan closure. Undertakes process improvement projects as necessary.
Coordinates Peer to Peer upon request.
Provides excellent customer service with every interaction and using the language of caring principles.
Monitors staff calls using the appropriate program to ensure staff is providing excellent customer service with each encounter internally and externally. Perform coaching as appropriate.
Perform other duties as assigned.

Qualifications

Bachelor degree in Nursing from an accredited Nursing program required, Masters degree preferred
Current California Registered Nurse (RN) license.
3 years of nursing experience required in acute care, emergency room, utilization review or compliance review required
3 years of experience in a supervisory/managerial position, required.
Knowledge of diagnosis and procedure coding practices
Knowledge of managed care environment
Knowledge of Federal, State, and Health Plan laws and regulations relevant to departmental operations and functions
Ability to utilize personal judgement and critical thinking to problem solve.
Ability to work collaborative and be a contributing member of a team
Ability to work independently with minimal supervision.
Communication: Ability to effectively communicate with individuals within all levels of the organization, patients, patient family members, providers, vendors and others.
Excellent customer service and telephone etiquette skills.
Microsoft & Computer Skills: Ability to utilize Microsoft Office applications (Word, Excel, Outlook, Power Point) and other computer software/applications
Time Management: Detail oriented and organizational skills. Ability to manage time effectively and prioritize tasks to meet established deadlines.
At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.