RN, Referrals Manager

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.

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 < 20%.
• 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 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.