Job Description

The Clinical Nurse Project Manager  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.

This role 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.

They will work closely with the coordinators in the department for clinical guidance on denial cases.

Qualifications

Education and/or Experience: 

• Active California LVN Or RN License
• Minimum of 3+ year of prior authorization/ denials experience
• Minimum of 1+ year of acute care/case management experience
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Knowledge of computers, faxes, printers and all other equipment
• Ability to deal with responsibility with confidential matters
• Ability to work in a multi-task, high stress environment

About the Hospital

As one of the largest physician-led networks in Southern California, we have thousands of physicians and hundreds of hospitals committed to providing quality healthcare to all of the communities we serve.

Every day, our employees are inspired to make a difference in the lives of others as well as transform their own experiences to achieve a higher sense of fulfillment. Our employees become a part of an extraordinary team of people dedicated to health, wellness, and happiness for themselves and others. There is no greater reward than contributing to a positive work environment where compassion, understanding, care and attention are encouraged and valued.