Nurse Supervisor, Denial Compliance Unit Um

Position Summary:

The Clinical Supervisor, UM Denial Compliance assures a high quality, efficient, timely and compliant denial process. Responsible to assure compliance with all applicable regulatory, accreditation and health plan requirements for Regal Medical Group, Lakeside Medical Group, and ADOC.

Essential Duties and Responsibilities include the following:

• Provide direct supervision to licensed and non-licensed denial unit staff, including, but not limited to daily work assignments, special project assignments, performance reviews and disciplinary actions as needed/required.
• Communicates effectively and collaborates with physician reviewers, medical directors, prior authorization teams, delegation oversight and other departments.
• Demonstrates the ability to follow through with requests, sharing of critical information, returning phone calls and getting back to individuals in a timely manner.
• Sets an example for staff by maintaining compliance and privacy, and reporting compliance and privacy issues and facilitating resolution of others’ issues.
• Assists as necessary in gathering/preparing necessary reports, such as department work-plans, quarterly/semi-annual/annual reports, inter-rater reliability surveys, and plan audits.
• Conducts internal quality monitoring for denial process.
• Develops and presents educational sessions for denial unit staff, medical directors and prior auth nurses to assure high quality compliant denial correspondence.
• Ensures compliance with regulatory, accreditation and delegated health plan requirements related to the denial process.
• Manages daily departmental functions including inventory management, turn-around-time compliance, reporting, staffing and supervision.
• Communicate effectively between nurse and physician reviewers, medical directors, and coordinators daily or as indicated regarding any denial issues.
• Assesses Medical Groups compliance with the regulatory and quality measures and develops strategies for improvement within the denial unit scope.
• Reviews reports, audit findings, appeal overturn data from Health Plans or other sources regarding group’s performance; identifies deficiencies, and develops and implements correction action plans and reassessment.
• Regularly reports departmental performance to leadership.
• Motivates, educates and provides assistance to staff.
• Stays abreast of state and federal regulations, standards, and reporting requirements as it relates to the department.
• Determines impact of implementation of new regulations and statutes and required notifications, changes, and training as it relates to the department.
• Communicates required changes, develops procedures, job aids, tools to assess risks, and leverages existing processes to facilitate required changes.
• In conjunction with direction, develops department objectives. Leads department to achievement of objectives.
• Provides professional/technical guidance to team members and stakeholders.
• Implements work processes and procedures to assure compliance with company policy.
• Influences others regarding existing concepts, processes and/or methodology.
• All other duties as directed by management

The pay range for this position at commencement of employment is expected to be between  $110,000 annually  - $120,000 annually for RN Supervisor ;pay will be $105,000/year to $106,000/year for LVN Supervisor  ; 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

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Education and / or Experience:

• Graduate from an accredited Registered Nursing Program with current/active license. RN preferred.
• Five years of progressive prior-authorization, appeals & grievance, health plan oversight or health plan compliance related experience in a health plan, medical group, IPA or management company required.
• Prior experience with project development and implementation, and have excellent organizational, interpersonal and analytical skills.
• Experience supervising staff and monitoring productivity/performance required. Experience with production environment preferred.
• Must have excellent communications skills both verbally and written.
• Ability to deal with responsibility with confidential matters.
• Must be able to handle multiple projects at one time in a high stress environment, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
• Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics.
• Must have the ability to work with all levels of management and have the ability to develop positive working relationships with health plan auditors and company department heads.
• Must have working knowledge of MS Office environment, and ability to function in highly computerized environment.
• Requires current CA driver’s license and car insurance.