The Denial Nurse is responsible for being the “second line” resource for preparing and maintaining health plan criteria for the campus Medical Directors.

This includes collaborating with each Health Plan to obtain updated/adequate criteria for each specialty to ensure that appropriate criteria are referenced upon furnishing a denial. This includes questions regarding procedures, training, and processes to assure compliance with RMG/LMG policies and procedures.

The Denial Nurse assists the campus Regional Medical Directors and Inpatient Manager/Supervisor with daily operations and management of denials, training, auditing functions, and assuring that all staff provides a level of patient services that meets or exceeds the organization’s expectations.  

Denial nurse will work collaboratively with Heritage and administration on the health plan template process.

Qualifications

• Active California Nursing License (RN or LVN).
• At least one year of prior authorization/ managed care experience.
• Typing 60 words per minutes with accuracy.
• Knowledge of computers, faxes, printers and all other equipment.
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
• 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.