Referral Nurse (Temp)

Job Description

The Referral Nurse is responsible for providing support to health network providers. Responsible to review Treatment Authorization Requests (TAR's)/Cerecons requests for approval, modification and works with Medical Director daily on denials and medical necessity reviews **

Responsibilities**

• Review of referrals to determine approval, modification or denial of services. Assure that utilization of referrals is completed within the proper time frames as specified by ICE and department standards.
• Use appropriate criteria and document reasoning in IDX notes. Critical thinking must be applied to each decision made. Ability to make independent decisions based on job knowledge or criteria.
• Identification of out of area providers and non-covered benefits.
• Ensure that correct supporting documentation is obtained to resolve referrals in a timely manner. Ensure the denial and appeal process is followed.
• Assist with education to providers regarding non-covered benefits, use of contracted providers and ancillary services.
• Consult with Medical Director for all possible denial of service and ensure required time-frame is sufficient for the Medical Director to make a decision in required time frame.
• Assist with PMM's (claims review) daily and provide determination on approval or denial review for daily check run.
• Identifies and refers cases appropriately for CCS, Homebound, High Risk, QI and Health Education, per policy, and documents referral in case file.

Qualifications

Minimum Education: High School Diploma or equivalent required. **

Minimum Experience: Minimum Three (3) years of UM referral review experience, preferably in a managed care setting, Health Plan or Medical Group. Understanding of criteria set by nationally recognized company (Milliman / InterQual).

Req. Certification/Licensure: Current California RN or LVN license (unrestricted)

About Us**

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.