Regal Medical Group · 17 hours ago
Director of Procedure & Training for Prior Auth & Denial Compliance
LA Metro Area
Full-time
Onsite
Director/Executive
$140K/yr - $150K/yrRegal Medical Group is one of the fastest growing Independent Physician Associations in Southern California, offering a supportive work environment. The Director of Procedure & Training for Prior Auth & Denial Compliance is responsible for developing and maintaining training materials and job aids to ensure compliance with regulatory requirements and improve the performance of the Prior Authorization team.
Health CareMedicalTherapeutics
Hiring Manager
Yvette Guerrero
Responsibilities
Develops, updates and maintains Prior Authorization Job Aids, procedures, program descriptions and related documents in compliance with DMHC, DHCS, CMS & NCQA requirements, as well as Health Plan contractual requirements, HPN Policies and direction from Compliance
Develops a process to keep up to date on regulatory and accreditation changes as well new and modified HPN policies and uses this information to proactively update trainings, job aids, and other helpful tools for Prior Authorization
Develops feedback mechanisms to ensure work being performed is delivering on needed results – i.e., meeting/exceeding compliance and service requirements
Develops, updates and maintains Prior Authorization compliance and procedural related training courses
Presents trainings in webinars or in-person as appropriate or needed
Reviews audit results (CQM, internal, HPN, health plans, regulatory, others) to review trends and collaboratively works with Prior Authorization management to develop the tools, trainings, job aids, communication tips, to support improved results as measured by audits and customer feedback
Develops, updates and maintains training materials to support Prior Authorization policies, procedures and job aids
Collaborates with PA leadership, Compliance, HPN, others to obtain consensus on job aids that are compliant with Policies and Procedures
Develops, updates and maintains job aids, workflows and training materials to improve the performance and consistency of Prior Authorization and develops an easily accessible staff resource center for PA
Identifies opportunities to improve quality, increase productivity and improve cycle time by reducing wasted time, errors, and rework resulting in business improvement
Works closely with Subject Matter Experts (SMEs) and process owners to successfully manage project timelines, progress reporting, recommendations, and implementation plans
Work with Decision Support to create automated auditing process for critical data elements when appropriate
Provide leadership with project status updates, feedback, and appropriate reporting on key responsibilities and objectives
Makes recommendations for improvements in systems, work process, job aids to improve the quality and productivity of the team
Develops positive customer relationships
Communicates effectively and interacts with the department managers, compliance officer, RMD and staff regarding all medical management processes
Participates in the quality monitoring and review process
All other duties as directed by management
Qualification
Required
Development of and maintenance of Prior Authorization and Denial Compliance Job Aids, Work Flows, procedures & related documents
Ensuring alignment with HPN and regulatory Policies and guidance in compliance with DMHC, DHCS, CMS & NCQA requirements
Development and maintenance of Prior Authorization training related to Prior Authorization
Identifying best practices and process improvements based on internal, health plan, regulatory, and HPN audits/reviews
Developing tools to assist the Prior Authorization management and staff in implementing new or updated Policies & Procedures
Reviewing results provided by HPN and internal oversight audits and monitoring mechanisms
Developing tools and aids to assist Prior Authorization in improving compliance and service results
Development of job aids & work flows as well as training materials (Presentation, delivery, tips, etc.)
Developing easily accessible and usable employee resource center for Prior Authorization job aids, training materials and other employee resources
Attending leadership and management meetings
Interface directly with the Medical Management, (UM & CM), Customer Service, Pharmacy, Compliance, Claims and other leaders and health plan representatives
Coordinating, planning and managing staff activities
Developing program goals and objectives with Medical Director
Making staff assignments
Developing or assisting in the development of related prior authorization and claims policy
Interpreting and administering pertinent laws
Evaluating staff and determining the quality of their work efforts
Developing and/or implementing effective ongoing programs to measure, assess and improve quality of processes and workflows
Developing productive work teams
Recommending disciplinary actions
Collaborating with clinical leadership for educational programs
Representing the department in meetings of professional and/or community organizations
Compiling data and preparing periodic reports
Coordinating and providing appropriate coverage
Maintaining contacts with individuals both within and outside of the department
Assuring optimal quality of care and service is provided
Participating in Quality Assurance Programs as needed
Intervening in crisis situations and investigating all unusual incidents
Leading and participating in meetings
Speaking on behalf of department
General knowledge of CMS and ICE UM processes/policies/procedures and timeliness standards
Management level experience including but not limited to: staff oversight, program management, and issue resolution
Benefits
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
401k Retirement Savings Plan
Income Protection Insurance
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
Company
Regal Medical Group
Regal Medical Group is an acute care community hospital that provides health care, therapies, pediatrics and dermatology services.
Founded in 1994
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Jennifer Dunphy, DrPH, MBA, MPH
Chief Population Health Officer | Senior Vice President
Jeanette Grandes
Executive Assistant to Senior Vice President and Chief Operations Officer
Recent News
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