Prior Authorization Administrative Reviewer

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. Essential Duties and Responsibilities include the following: 1. Understand, promote and manage with the principles of medical management to facilitate the right care at the right time in the right setting. 2. As part of a team of medical directors, nurses and coordinators, participates in the pre-service medical necessity review of patient care. 3. Reviews prior authorization requests for medical necessity with respect to Health Plans, CMS, third-party guidelines (i.e., McKesson InterQual, American Imaging Management, USPSTF) and medical group Medical Policies and Clinical Guidelines. 4. Does internet searches for other existing policies/guidelines/medical necessity indications for requested services in order to facilitate quality, cost-effective care. 5. Identify high-risk patients and help coordinate care with the high-risk team. 6. In collaboration with the Medical Director may identify needs for and participates in the development and implementation of Care Management/Utilization Management policies and procedures to promote cost-effectiveness quality medical care. Education and/or Experience: 1. Doctor of Medicine degree. 2. Specialty training preferred. 3. Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred. 4. Must demonstrate a strong clinical fund of knowledge. 5. Must have familiarity with the principles of clinical research and have the ability to interpret and apply clinical guidelines and policies. 6. Strong proficiency in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) and ability to conduct research over the internet. 7. Must have excellent communications skills both verbally and written. 8. Typing 50 words per minutes with accuracy. 9. Ability to deal with responsibility with confidential matters. 10. Must have strong organization skills. 11. Ability to work in a multi-task, high stress environment. 12. Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities. 13. Must be self-motivated, self-guiding, driven, and have high personal ethics. 14. Must have the ability to work with all levels of management and have the ability to develop positive working relationships with medical directors and company department heads. We offer a full benefits package which includes employer paid medical, pharmacy and dental benefits. We offer a generous PTO package, 401k Retirement Savings, Life Insurance, Flexible Spending Account (FSA), Tuition Reimbursement & Licensed Renewal Fees for our clinical staff. 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.