Prior Authorization Nurse (LVN)

Case Manager Prior Authorization LVN

The Case Manager Prior Authorization LVN is responsible for supporting the process that manages all outpatient services, including other Prior Authorization Nurses. The goal of the Lead 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 Lead is to model for the PANs proper process and procedure as well as cooperation and support to the other PANs, physician reviewers, Supervisor(s)/Manager(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:

• Understand, promote and audit the principles of M. to facilitate the right care at the right time in the right setting.
• Communicate effectively and interact with the provider group, staff and health plans daily or as indicated regarding PA and referral authorization issues.
• Identify and handle requests that can be approved and brought to resolution based on referral guidelines.
• Verify that any new process that is implemented is followed by the PA staff via daily/weekly audits and provided mentoring as needed.
• Act as a liaison between Medical Directors and Physician Reviewers to ensure in their queues are processed within standard turnaround times.
• Assist the supervisor, manager, Medical Directors and ancillary staff in obtaining additional information and processing difficult or escalated cases.
• Participate in the new PAN on boarding process by providing training and shadowing in the different clinical review modules.
• Maintain knowledge of all Business Rules and be able to float to provide coverage for vacations and call outs.
• Ensure that all referrals are processed within standard turnaround times and review referrals that may fall out of compliance.
• Auditing of work:
  • Weekly/daily auditing of PAN/PACC production and provide mentoring as
  • Weekly/daily auditing of PAN/PACC quality and provide mentoring as
  • Verify that all urgent referrals are processed timely via weekly/daily audits and provide mentoring as needed
  • Verify that all standard referrals are processed timely via weekly/daily audits and provide mentoring as needed.
• All other duties as directed by management.

Organizational Responsibilities:

• Proactively support and practice company mission, vision and values.
• Follow Employee Handbook guidelines and company policies and procedures.
• Follow established departmental dress code.
• Appropriately and accurately maintain time keeping records.
• Adhere to attendance policy and time off requests.
• Follow safety policies and procedures.
• Be flexible and adaptable and courteous and promote professionalism.
• Communicate verbally and in writing through appropriate channels.
• Maintain confidentiality at all times in compliance with company policy and HIPAA requirements.
• Employee has completed all required annual Compliance training and signed attestation form is attached for each module.

The pay range for this position at commencement of employment is expected to be between $37.50 -$40/hour for LVNs; 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

Education and/or Experience:

• Graduate of an accredited nursing program
• Active California Licensed Vocational Nurse License
• At least one year of prior authorization/managed care experience in a leadership role
• Knowledge of computers, faxes, printers and all other equipment
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Typing 30 WPM with accuracy
• Ability to deal with responsibility with confidential matters
• Ability to work in a multi-task, high stress environment