Sales Executive

3 weeks ago

Riyadh, Saudi Arabia Props Box Full time
*hybrid*

JobSummary

This position isresponsible for reviewing and processing requests forauthorization and notification of medical services from healthprofessionals, clinical facilities, and ancillaryproviders. The incumbent will be responsible for priorauthorization and referral related processes that includes on-lineresponsibilities as well as selected off-line tasks. Utilizes ourmedical criteria, policies, and procedures to authorize referralrequests from medical professionals, clinical facilities, andancillary providers. This position directly interacts with providercallers and serves as a resource for theirneeds.

PositionResponsibilities:

  • Reviewsrequests for medicalappropriateness.
  • Verifies andprocesses specialty referrals, diagnostic testing, outpatientprocedures, home health care services and durable medical equipmentand supplies via telephone or fax by using established clinicalprotocols to determine medicalnecessity.
  • Screen requests for theMedical Director review, gathers pertinent medical informationprior to submission to the Medical Director; follows up with therequester by communicating the Medical Director s decision;documents follow-up in the utilization managementsystem.
  • Completes requireddocumentation for data entry into the utilization management systemat the time of the telephone call of fax to include anyauthorization updates.
  • ReviewsICD-10, CPT-4 and HCPCS codes for accuracy and existence ofcoverage specific to the line ofbusiness.
  • Contacts the HealthNetworks and/or CalOptima Customer Service regarding health networkenrollments.
  • Identifies and reportsany complaints to immediate supervisor utilizing the call trackingsystem, or through verbal communication if the issue is of urgentnature.
  • Refers cases of possibleover/under utilization to the Medical Director for properreporting.
  • Meets productivity andquality of work standards on an ongoingbasis.
  • Travel to locations withfrequency as the employer determines is necessary or desirable tomeet its businessneeds.


Requirements

Experience&Education:

  • Current,unrestricted Licensed Vocational Nurse (LVN) license to practice inthe State of California required.
  • 3+years of Nursing experience of which 1+ year as a Clinical NurseReviewer required.
  • 1+ years ofUtilization Management/ Prior Authorization Review experiencerequired.
  • Have access means oftransportation for work away from the primary office approximately5% of thetime.

PreferredQualifications:

  • ManagedCare experience preferred.
  • ActiveCertified Case Manager (CCM) certificationpreferred.

Knowledgeof:

  • CurrentCPT-4, ICD-10, and Healthcare Common Procedure Coding System(HCPCS) codes and continual updates to knowledge base regarding thecodes.
  • MedicalTerminology.
  • Medi-Cal and Medicarebenefits andregulations.

Benefits

AtSunshine Enterprise USA LLC, we firmly believe that our employeesare the heartbeat of our organization and we are happy to offer thefollowingbenefits:

Competitivepay & weeklypaychecks

Health,dental, vision, and lifeinsurance

401(k)savingsplan

Awardsand recognitionprograms

Benefiteligibility is dependent on employmentstatus.


SunshineEnterprise USA is an Equal Opportunity Employer Minorities,Females, Veterans and DisabledPersons"



Experience & Education: Current, unrestricted LicensedVocational Nurse (LVN) license to practice in the State ofCalifornia required. 3+ years of Nursing experience of which 1+year as a Clinical Nurse Reviewer required. 1+ years of UtilizationManagement/ Prior Authorization Review experience required. Haveaccess means of transportation for work away from the primaryoffice approximately 5% of the time. Preferred Qualifications:Managed Care experience preferred. Active Certified Case Manager(CCM) certification preferred. Knowledge of: Current CPT-4, ICD-10,and Healthcare Common Procedure Coding System (HCPCS) codes andcontinual updates to knowledge base regarding the codes. MedicalTerminology. Medi-Cal and Medicare benefits andregulations.

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