RN, Referrals Manager

About the role

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.

Responsibilities

• Provides daily oversight of all personnel within the Referral Department, ensuring all regulatory requirements are met.
• Keeps up to date with all HPN, DOHC Policies and Procedures and develops appropriate job aids to assist staff.
• Oversees and manages departmental training and orientation of new employees.
• Collaborates closely with Senior Medical Director, Senior Director and Senior Coordinators to ensure all turn-around times are met, proper documentation is performed, appropriate criteria are pulled, correct templates are used and files are processed timely and correctly.
• Tracks and trends data to fix problems before they impact reporting or audits.
• Provides expert knowledge to other departments and their staff regarding contracts, processing, benefits and criteria.
• Serves as 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 referrals.
• Participates in CMS, DMHC, DHCS, and Health Plan audits.
• Works closely with Senior Director 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 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.
• Performs coaching as appropriate.

Qualifications

• Bachelor degree in Nursing from an accredited Nursing program required; Master’s degree preferred.
• Current California Registered Nurse (RN) license.
• 3 years of nursing experience required in acute care, emergency room, utilization review or compliance review.
• 3 years of experience in a supervisory/managerial position.
• 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 judgment and critical thinking to problem solve.
• Ability to work collaboratively 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 and Computer Skills: Ability to utilize Microsoft Office applications (Word, Excel, Outlook, PowerPoint) and other computer software/applications.
• Time Management: Detail oriented with organizational skills. Ability to manage time effectively and prioritize tasks to meet established deadlines.

Physical Demands

• Sitting: Approximately 70% of day.
• Standing: Approximately >15% of day.
• Walking: Approximately >15% of day.
• Lifting: 0–20 lbs. (equipment, supplies) approximately >10% of day.
• Bending: Approximately >10% of day.
• Kneeling:
• Hearing/Visual Acuity: Adequate for use with computers, telephone and/or Blackberry. Approximately 50% of day.
• Computer: Highly technical work environment. Must be able to work a minimum of 6 hours a day using keyboard, mouse and monitor.
• Reaching: Above head 75 degrees approximately 25% of day.
• Hand grip dexterity: Approximately 40% of day.