CalOptima
Orange, CA, USA
Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) Job Description Department(s): Utilization Management (Prior Authorization) Reports to: Manager, Utilization Management FLSA status: Non-Exempt Salary Grade: K - $70,000 - $114,268 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday, April 03, 2024 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About the Position The Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) will be responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes, including on-line responsibilities and select off-line tasks. The incumbent will utilize CalOptima Health's medical criteria, policies and procedures to authorize referral requests from medical professionals, clinical facilities and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs. Duties & Responsibilities: Medical Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Reviews requests for medical appropriateness. Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax using established clinical protocols to determine medical necessity. Screens requests for the Medical Director's review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director's decision and documents follow-ups in the utilization management system. Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates. Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business. Contacts the health networks and/or CalOptima Health's Customer Service department regarding health network enrollments. Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent. Refers cases of possible over/under utilization to the Medical Director for proper reporting. Meets productivity and quality of work standards on an ongoing basis. Administrative Support Assists the manager with identifying areas of staff training needs and maintains current data resources. Completes other projects and duties as assigned. Experience & Education: High School diploma or equivalent required. Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required. 3 years of nursing experience required, 1 year of which must be as a Nurse Reviewer. 1 year of utilization management/prior authorization review experience required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. Preferred Qualifications: Active Certified Case Manager (CCM) certification. Managed care experience. Physical Demands and Work Environment: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: While performing duties of job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting. Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4564 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-f0c20222ebb4944b855cfc1276172545
Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) Job Description Department(s): Utilization Management (Prior Authorization) Reports to: Manager, Utilization Management FLSA status: Non-Exempt Salary Grade: K - $70,000 - $114,268 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday, April 03, 2024 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About the Position The Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) will be responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes, including on-line responsibilities and select off-line tasks. The incumbent will utilize CalOptima Health's medical criteria, policies and procedures to authorize referral requests from medical professionals, clinical facilities and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs. Duties & Responsibilities: Medical Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Reviews requests for medical appropriateness. Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax using established clinical protocols to determine medical necessity. Screens requests for the Medical Director's review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director's decision and documents follow-ups in the utilization management system. Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates. Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business. Contacts the health networks and/or CalOptima Health's Customer Service department regarding health network enrollments. Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent. Refers cases of possible over/under utilization to the Medical Director for proper reporting. Meets productivity and quality of work standards on an ongoing basis. Administrative Support Assists the manager with identifying areas of staff training needs and maintains current data resources. Completes other projects and duties as assigned. Experience & Education: High School diploma or equivalent required. Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required. 3 years of nursing experience required, 1 year of which must be as a Nurse Reviewer. 1 year of utilization management/prior authorization review experience required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. Preferred Qualifications: Active Certified Case Manager (CCM) certification. Managed care experience. Physical Demands and Work Environment: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: While performing duties of job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting. Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4564 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-f0c20222ebb4944b855cfc1276172545
CalOptima
Orange, CA, USA
Supervisor, Utilization Management (Prior Authorizations) Job Description Department(s): Utilization Management Reports to: Manager Utilization Management FLSA status: Non - Exempt Salary Grade: N - $95,000 - $155,078 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday, January 25, 2024 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About the Position The Supervisor Utilization Management (Prior Authorization) will monitor and supervise the department operations to ensure service standards are met. The incumbent will make recommendations regarding assignments based on assessment of workload serve as a resource to the Prior Authorization staff regarding CalOptima Health's policies and procedures and regulatory requirements governing authorization processing. The incumbent will provide ongoing monitoring and development of staff. Duties & Responsibilities: Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Assists the manager as needed to ensure departmental and agency goals are met. Assists in the monitoring of appropriate benefit checks, application of guidelines to determine medical necessity, appropriate routing and timely completion of authorization requests. Assists with the collection, monitoring and analysis of prior authorization indicators and activities. Reviews workflows, procedures and/or policies and recommends or implements changes as appropriate. Provides coverage and expertise for other teams within the Utilization Management department. Conducts prior authorization presentations to internal or external customers. Identifies new learning opportunities for staff and develops training materials (e.g., desktop procedures and/or Microsoft PowerPoint presentations) to provide education. Serves as a subject matter expert (SME) to departmental staff, internal departments and affiliated health networks regarding authorization rules and processes. Creates staffing assignments based on authorization priority, workload, current staffing and review of timeliness reports. Performs interviews of potential candidates and makes recommendations for second round interviews and/or hiring of a candidate. Trains, audits, supervises and coaches Prior Authorization staff. Conducts performance feedback and/or counseling/corrective action meetings in collaboration with Human Resources as applicable. Identifies and conducts performance feedback and/or counseling/corrective action meetings with the assistance of Human Resources as necessary. Completes other projects and duties as assigned. Experience & Education: Associate's degree in Nursing (ADN) required. Current and unrestricted California Board Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license required. 3 years of clinical nursing experience required, preferably in a managed care environment. 2 years of progressive leadership experience, including direct supervision of staff in managed care and/or utilization management required. 1 year of utilization management/prior authorization review experience required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. Preferred Qualifications Bachelor's degree in Nursing (BSN). Physical Demands and Work Environment: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: While performing duties of the job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case while traveling, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use in meetings, face-to-face interaction and while presenting. Work environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4505 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-bb12d055f63b6c46a652ab321528b57b
Supervisor, Utilization Management (Prior Authorizations) Job Description Department(s): Utilization Management Reports to: Manager Utilization Management FLSA status: Non - Exempt Salary Grade: N - $95,000 - $155,078 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday, January 25, 2024 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About the Position The Supervisor Utilization Management (Prior Authorization) will monitor and supervise the department operations to ensure service standards are met. The incumbent will make recommendations regarding assignments based on assessment of workload serve as a resource to the Prior Authorization staff regarding CalOptima Health's policies and procedures and regulatory requirements governing authorization processing. The incumbent will provide ongoing monitoring and development of staff. Duties & Responsibilities: Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Assists the manager as needed to ensure departmental and agency goals are met. Assists in the monitoring of appropriate benefit checks, application of guidelines to determine medical necessity, appropriate routing and timely completion of authorization requests. Assists with the collection, monitoring and analysis of prior authorization indicators and activities. Reviews workflows, procedures and/or policies and recommends or implements changes as appropriate. Provides coverage and expertise for other teams within the Utilization Management department. Conducts prior authorization presentations to internal or external customers. Identifies new learning opportunities for staff and develops training materials (e.g., desktop procedures and/or Microsoft PowerPoint presentations) to provide education. Serves as a subject matter expert (SME) to departmental staff, internal departments and affiliated health networks regarding authorization rules and processes. Creates staffing assignments based on authorization priority, workload, current staffing and review of timeliness reports. Performs interviews of potential candidates and makes recommendations for second round interviews and/or hiring of a candidate. Trains, audits, supervises and coaches Prior Authorization staff. Conducts performance feedback and/or counseling/corrective action meetings in collaboration with Human Resources as applicable. Identifies and conducts performance feedback and/or counseling/corrective action meetings with the assistance of Human Resources as necessary. Completes other projects and duties as assigned. Experience & Education: Associate's degree in Nursing (ADN) required. Current and unrestricted California Board Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license required. 3 years of clinical nursing experience required, preferably in a managed care environment. 2 years of progressive leadership experience, including direct supervision of staff in managed care and/or utilization management required. 1 year of utilization management/prior authorization review experience required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. Preferred Qualifications Bachelor's degree in Nursing (BSN). Physical Demands and Work Environment: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: While performing duties of the job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case while traveling, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use in meetings, face-to-face interaction and while presenting. Work environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4505 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-bb12d055f63b6c46a652ab321528b57b