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