Referral Nurse - Full Time, Days

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Referral Nurse is responsible for providing support to health network providers. Responsible to review Treatment Authorization Requests (TAR's)/Cerecons requests for approval, modification and works with Medical Director daily on denials and medical necessity reviews.

Job Responsibilities/Duties

• Review of referrals to determine approval, modification or denial of services. Assure that utilization of referrals is completed within the proper time frames as specified by ICE and department standards.
• Use appropriate criteria and document reasoning in IDX notes. Critical thinking must be applied to each decision made. Ability to make independent decisions based on job knowledge or criteria.
• Identification of out of area providers and non-covered benefits.
• Ensure that correct supporting documentation is obtained to resolve referrals in a timely manner. Ensure the denial and appeal process is followed.
• Assist with education to providers regarding non-covered benefits, use of contracted providers and ancillary services.
• Consult with Medical Director for all possible denial of service and ensure required time-frame is sufficient for the Medical Director to make a decision in required time frame.
•  Assist with PMM's (claims review) daily and provide determination on approval or denial review for daily check run.
• Identifies and refers cases appropriately for CCS, Homebound, High Risk, QI and Health Education, per policy, and documents referral in case file.

Qualifications

Minimum Education: High School Diploma or equivalent required.

Minimum Experience: Minimum Three (3) years of UM referral review experience, preferably in a managed care setting, Health Plan or Medical Group.  Understanding of criteria set by nationally recognized company (Milliman / InterQual).

Req. Certification/Licensure: Current California RN or LVN license (unrestricted).

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol.  Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm.  For this reason, we require applicants to pass a screening for drug use as a condition of employment.  This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.

How to Apply

To apply for this role, or search our other openings, please visit   http://pmh.com/careers/  and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm