RN, Referrals Manager

Desert Oasis Healthcare; Palm Springs (CA); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Desert Oasis Healthcare seeks a RN Supervisor to oversee the daily operations of the referral and prior authorization processes in California. You will ensure accurate coding, manage staff, and enforce CMS and health plan compliance standards.

Collaborate with Senior Medical Director and other leaders to meet turnaround times, provide training, and serve as the main contact for IPA inquiries. Strong communication and leadership are essential.

Qualifications

• Registered nurse with CA license and nursing degree.
• Minimum 3 years in acute care, ER, utilization review, or compliance.
• 3+ years in a supervisory/managerial position.
• Knowledge of diagnosis and procedure coding.
• Knowledge of managed care environment and relevant regulations.
• Strong problem-solving and independent-working abilities.
• Effective communication and customer service skills.

Responsibilities

• Oversee daily operations of Referral Dept and regulatory compliance.
• Coordinate departmental training and onboarding of new staff.
• Collaborate with senior leaders to meet turn-around times and documentation standards.
• Serve as main contact for IPA/Health Plan inquiries and provide department expertise.
• Monitor productivity and provide coaching based on analytics.
• Act as primary clinical resource for the department and offshore vendors.
• Participate in CMS, DMHC, DHCS audits and root cause analysis.
• Coordinate Peer to Peer requests.
• Deliver excellent customer service in every interaction.
• Monitor staff calls and provide coaching as needed.
• Perform additional duties as assigned.

Skills

Nursing experience

Supervisory skills

Critical thinking

Communication skills

Time management

Education

Bachelor degree in Nursing

Tools

Microsoft Office

Job description

Oversees and directs the daily operations of the complete prior authorization process, including; validation of accurate ICD, CPT and HCPC codes, hierarchy of Health Plan and CMS criteria for clinical review and UM approvals, Medical Director determinations and provider/member letter notifications.

Professional Duties

• Provides daily oversight of all personnel with the Referral Dept, ensuring all regulatory requirements are met. Additionally keeps up to date with all HPN, DOHC Polices and Procedures and develops appropriate job aids to assist the staff.
• Oversee and manage in departmental training and orientation of new employees.
• Collaborates closely with Senior Medical Director, Senior Director and Senior Coordinators to ensure all turn-round times are met, proper documentation is performed, appropriate criteria pulled, correct templates are used and files are processed timely/correctly. Tracks and trends data to fix a problem before it impacts our reporting or audits.
• Provides expert knowledge to other departments and their staff regarding contracts, processing, benefits and criteria. Additionally, is the main contact for any IPA or Health Plan inquiries.
• Performs ongoing monitoring and analytic review of productivity followed by any appropriate coaching or in-service to the Team.
• Serves as the primary clinical resource for the department, as well as any offshore Vendors used in the processing of the referrals.
• Participates in CMS, DMHC, DHCS, and Health Plan audits. Works closely with Senior Direct to complete root cause analysis and Corrective Action Plan closure. Undertakes process improvement projects as necessary.
• Coordinates Peer to Peer upon request.
• Provides excellent customer service with every interaction and using the language of caring principles.
• Monitors staff calls using the appropriate program to ensure staff is providing excellent customer service with each encounter internally and externally. Perform coaching as appropriate.
• Perform other duties as assigned.

Qualifications

• Bachelor degree in Nursing from an accredited Nursing program required, Masters degree preferred
• Current California Registered Nurse (RN) license.
• 3 years of nursing experience required in acute care, emergency room, utilization review or compliance review required
• 3 years of experience in a supervisory/managerial position, required.
• Knowledge of diagnosis and procedure coding practices
• Knowledge of managed care environment
• Knowledge of Federal, State, and Health Plan laws and regulations relevant to departmental operations and functions
• Ability to utilize personal judgement and critical thinking to problem solve.
• Ability to work collaborative and be a contributing member of a team
• Ability to work independently with minimal supervision.
• Communication: Ability to effectively communicate with individuals within all levels of the organization, patients, patient family members, providers, vendors and others.
• Excellent customer service and telephone etiquette skills.
• Microsoft and Computer Skills: Ability to utilize Microsoft Office applications (Word, Excel, Outlook, Power Point) and other computer software/applications
• Time Management: Detail oriented and organizational skills. Ability to manage time effectively and prioritize tasks to meet established deadlines.
• At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.

Physical Demands

Type Description

Sitting

Approximately 70% of day.

Standing

Approximately > 15% of day.

Walking

Approximately > 15% of day.

Lifting

0 - 20 lbs. (equipment, supplies) approximately >10% of day.

Bending

Approximately >10% of day. Kneeling <20%.

Hearing/Visual Acuity

Adequate for use with compu ers, telephone and/or Blackberry. Approximately 50% of day.

Computer

Highly technical work environment. Must be able to work minimum of 6 hours a day using keyboard, mouse and monitor.

Reaching

Above head 75 degrees approximately 25% of day.

Hand grip dexterity

Approximately 40% of day.