Do you want to work with a team who values both professional and personal growth while also receiving fantastic benefits? We are looking for a Referral Nurse to work remotely with Health Plan of San Joaquin who has strong clinical skills and a passion to help fulfill our mission to continuously improve the health of our community.
What You Will Be Doing
- Reviews and verifies authorizations and supporting documentation for accuracy and completeness, including but not limited to eligibility, codes, and clinical notes.
- Obtains required documentation and information from a variety of internal and external sources.
- Determines if request meets established medical guidelines, and approves, defers, or escalates to Medical Director for review.
- Monitors deferrals and escalated requests to ensure timely responses.
- Prepares communications, including denial, approved with modifications and deferral letters using standard templates; submits for approval and distributes.
Required Skills
What You Bring
Knowledge, Skills, Abilities and Competencies
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Strong clinical skills as defined in California scope of practice guidelines for LVN’s and/or RN’s.
- Strong knowledge of and proficient skills in administering protocols.
- Ability to read and apply clinical information, practice guidelines and other complex data and information.
- Strong assessment and analytical skills, with ability to determine key issues, develop effective action plans and implement to successful conclusion.
- Interpersonal skills – interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong oral and written communication skills, with the ability to communicate professionally to diverse individuals, effectively explain complex information and document according to standards.
- Strong listening skills, with the ability to accurately receive and understand messages.
- Strong conflict resolution skills, including but not limited to the ability to use tact and diplomacy to diffuse emotional situations.
- Ability to work independently and as part of a team.
- Demonstrated commitment to HPSJ’s strategy, vision, mission and values.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Basic problem solving and analytical skills, including the ability to perform routine analysis and solve problems using identified data and information.
- Basic skills in Windows, Word, Excel and Outlook.
- Ability to enter data into and navigate through multiple databases.
- Basic arithmetic skills.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion
Preferred
- Knowledge of NCQA standards as they apply to authorizations and referrals.
- Knowledge of the principles and practices of managed care
- Knowledge of Medi-Cal and/or Medicare regulations as they apply to authorizations and referrals
Required Experience
What You Have:
Education & Experience
Required
- Graduation from an accredited nursing school; and
- At least one year of clinical experience.
Preferred
- Bachelor’s Degree
Licensure, Certification, Registration
- Unrestricted California Vocational Nurse license; OR
- Unrestricted California Registered Nurse license
Source: Indeed.com
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