Nurse Trainer, Utilization Management (UM)

Regal Medical Group; Lima Metropolitana; On-site; PEN 332,150 - 405,962; Full time

Job summary

A leading medical group is seeking a professional to promote quality and cost-effectiveness in medical care. The role involves processing denial letters, collaborating with clinical teams, and ensuring adherence to policies. Candidates should have significant experience in prior authorization and case management, with strong communication skills and proficiency in MS Office.

Qualifications

• 3+ years in prior authorization/denials.
• 1+ year in acute care/case management.
• Proficient in MS Office applications.

Responsibilities

• Process denial letters and interpret denial language.
• Collaborate with department coordinators for clinical guidance.
• Document necessary information accurately in authorization notes.

Skills

Communication

Teamwork

Time Management

Confidentiality

Multi-tasking

Education

3+ years of prior authorization/denials experience

1+ year of acute care/case management experience

Tools

MS Office

Job description

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This role will promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to denials. This role will review for appropriate care and setting, and follow guidelines/policies as they relate to the review process. It will be responsible for processing denial letters for all affiliated groups, interpreting denial language provided by the prior authorization nurse, coordinators, and medical directors, and placing it into the appropriate templates while translating medical terminology into lay language and grading the reading level as appropriate. Collaboration with department coordinators for clinical guidance on denial cases is essential.

Essential Duties and Responsibilities include:

1. Understand all aspects of Access Express concerning prior authorization and denials.
2. Complete assigned tasks accurately and within specified time limits.
3. Maintain smooth working relations with co-workers and supervisors, being a “Team Player”.
4. Anticipate future events, set realistic goals, timetables, and coordinate activities to ensure smooth workflow and time management.
5. Understand, promote, and review the principles of medical management to facilitate appropriate care.
6. Understand all Regal Medical Management policies and procedures.
7. Communicate effectively with department managers, nurses, coordinators, regional medical directors, and staff regarding denials processes.
8. Speak concisely and tactfully on all subjects related to Denials.
9. Maintain relationships with denials coordinators, prior auth teams, pharmacy, medical directors, and network management.
10. Maintain regulatory Turnaround Time Standards per guidelines.
11. Document all necessary information accurately in authorization notes.
12. Communicate with prior auth teams and medical directors for denials needing clarification, providing case summaries and recommendations.
13. Follow through with requests, share critical information, and respond promptly.
14. Identify departmental needs and report to management for improvements.
15. Perform all other duties as directed by management.

Organizational Responsibilities:

1. Support and practice the company's mission, vision, and values proactively.
2. Follow Employee Handbook, policies, and procedures.
3. Adhere to the departmental dress code.
4. Maintain accurate timekeeping records.
5. Follow attendance policies and request time off appropriately.
6. Follow safety policies and procedures.
7. Be flexible, adaptable, courteous, and promote professionalism.
8. Communicate effectively verbally and in writing.
9. Maintain confidentiality in compliance with policies and HIPAA.
10. Complete required annual Compliance training and sign the attestation form for each module.

Education and/or Experience:

• Minimum of 3+ years of prior authorization/denials experience.
• Minimum of 1+ year of acute care/case management experience.
• Proficient in MS Office (Word, Excel, Outlook, Access, PowerPoint).
• Knowledge of computers, faxes, printers, and equipment.
• Ability to handle confidential matters responsibly.
• Ability to work in a multi-tasking, high-stress environment.

The pay range at the start of employment is expected to be up to $104,000 annually, depending on licensure and other individualized factors such as market location, skills, and experience.