Job Description

We are seeking experienced Denial Nurses to join our team and enhance the quality and cost-effectiveness of our medical care services.

The Denial Nurse plays a crucial role in reviewing and processing insurance claim denials, ensuring appropriate care and adherence to guidelines.

Their responsibilities include:

• Reviewing cases for appropriate care and setting, following established guidelines and policies related to denials
• Processing denial letters for all affiliated groups using appropriate templates.
• Interpreting denial language from prior authorization nurses, coordinators, and medical directors.
• Translating medical terminology into lay language, adjusting the reading level for better comprehension
• Collaborating closely with department coordinators for clinical guidance on complex denial cases.
• Understanding and utilizing Access Express functionality for prior authorization and denials management.
• Completing assigned tasks accurately and within specified time limits.
• Maintaining effective working relationships with co-workers, supervisors, and other departments.
• Promoting and reviewing medical management principles to ensure appropriate care delivery.
• Communicating effectively with department managers, nurses, coordinators, regional medical directors, and staff regarding denial processes.
• Acting as a liaison between prior authorization coordinators, nurses, and medical directors when necessary.
• Maintaining regulatory turnaround time standards per guidelines.
• Documenting all necessary information accurately and completely in authorization notes.
• Providing accurate case summaries and recommendations for denials needing clarification.
• Identifying improvement opportunities within the denials department and reporting to management.

The Denial Nurse must possess strong analytical skills, clinical expertise, and the ability to communicate complex medical information effectively to diverse audiences. They play a critical role in ensuring fair and appropriate coverage decisions while maintaining clear communication with all parties involved in the healthcare process.

The pay range for this position at commencement of employment is expected to be between $37.50 per hour - $50.00 per hour depending on licensure ; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

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