Authorizations and Referrals Review RN – Health Plan of San Joaquin – French Camp, CA

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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