A rapidly expanding healthcare management organization is seeking an experienced RN or LVN with strong background in utilization management, authorizations, and hospital denial reviews. This role supports insurance-side clinical operations and requires deep familiarity with California insurance regulations, utilization management standards, and HMO/Medicare Advantage processes. The ideal candidate has 3–5 years of experience in UM or case management, understands authorization workflows, and is comfortable overseeing departmental processes.
Responsibilities:
- Lead and support multiple operational and UM/QM projects from planning through execution.
- Oversee prior authorizations, referrals, denials, CAP responses, and pending authorizations.
- Ensure compliance with all local, state, and federal healthcare regulations and HIPAA.
- Monitor provider and patient satisfaction surveys; report quality concerns.
- Supervise, train, coach, and audit Prior Authorization Coordinators and Nursing staff.
- Act as liaison between coordinators, nurses, providers, internal departments, and leadership.
- Review escalated cases, resolve complex authorization and denial issues.
- Audit referral documentation weekly for accuracy and compliance.
- Maintain detailed project plans, tracking tools, and documentation.
- Ensure productivity, turnaround times, and quality benchmarks are met.
- Assist with staffing coverage and shifting operational priorities as needed.
- Provide operational and clinical support to leadership for daily workflow needs.
- Other duties as assigned.
Requirements:
- Active RN or LVN license required.
- 5+ years experience in healthcare referral management, utilization management, or prior authorization.
- Strong working knowledge of Medicare, Commercial, and Medi-Cal authorization processes.
- Experience with denials, appeals, and regulatory compliance.
- Experience working across multiple EMR and authorization systems.
- Proven leadership, auditing, and staff coordination abilities.
Key Skills:
- Strong clinical judgment and analytical decision-making.
- Excellent verbal and written communication skills.
- Advanced problem-solving and negotiation abilities.
- High attention to detail and documentation accuracy.
- Ability to manage multiple priorities in a fast-paced environment.
- Strong customer service and provider-relationship management skills.
- Proficiency with Microsoft Office and healthcare software systems.
- Positive, team-oriented leadership style.
LVN: 70K-90K ; RN: 100K-150K.