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.
We currently have an opening for Clinical Nurse Reviewer.
The Tertiary Nurse Reviewer is responsible for supporting the process that manages all hospital and skilled nursing admissions, concurrent review, and discharge planning. The goal of the Tertiary Nurse Reviewer is to effectively support the inpatient management process by assuring the right information is provided timely to the RMG administrative management team, hospitalists' and care managers. This position is crucial, in an effort to minimize unnecessary admissions and excessive length of stay at tertiary facilities.
Assesses and develops a care plan in collaboration with referring physicians, and other healthcare practitioners
The goal of the Tertiary 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.
Minimize unnecessary internal referrals to Tertiary facilities while member is admitted.
Secure solid discharge planning and transition to community provider once stable.
Maximize use of community providers capable of providing higher level of care versus USC or tertiary facilities.
Help work with Tertiary RMD to provide direct feedback to case managers to minimize errors in level of care, admit date, and discharge dates and to minimize "mismatched" errors that delay claims payments.
Provide direct feedback to Case Manager's to minimize errors in level of care, admit date, and discharge dates and to minimize "mismatched" errors that delay claims payment.
Work with CMO to facilitate language into contracts to ensure accurate claims payment.
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 followup with an upset customer, gathering information, and demonstrates empathy.
Education and/or Experience:
Graduate from an accredited Registered Nursing (RN) program or Licensed Vocational Nursing (LVN) program
Typing 60 words per minutes with accuracy.
Minimum of 2 years relevant work experience in a managed care setting, health plan, or large medical group administration.
Excellent verbal and written communication skills.
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.
We offer a full benefits package which includes employer paid medical, pharmacy and dental benefits. We offer a generous PTO package, 401k Retirement Savings, Life Insurance, Flexible Spending Account (FSA), Tuition Reimbursement & Licensed Renewal Fees for our clinical staff.
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.