Sales Executive

Job Summary

This position is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes that includes on-line responsibilities as well as selected off-line tasks. Utilizes our medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. This position directly interacts with provider callers and serves as a resource for their needs.

Position Responsibilities:

• Reviews requests for medical appropriateness.
  
• Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity.
  
• Screen requests for the Medical Director review, gathers pertinent medical information prior to submission to the Medical Director; follows up with the requester by communicating the Medical Director s decision; documents follow-up in the utilization management system.
  
• Completes required documentation for data entry into the utilization management system at the time of the telephone call of fax to include any authorization updates.
  
• Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage specific to the line of business.
  
• Contacts the Health Networks and/or CalOptima Customer Service regarding health network enrollments.
  
• Identifies and reports any complaints to immediate supervisor utilizing the call tracking system, or through verbal communication if the issue is of urgent nature.
  
• Refers cases of possible over/under utilization to the Medical Director for proper reporting.
  
• Meets productivity and quality of work standards on an ongoing basis.
  
• Travel to locations with frequency as the employer determines is necessary or desirable to meet its business needs.
  

Requirements

Experience & Education:

• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the State of California required.
  
• 3+ years of Nursing experience of which 1+ year as a Clinical Nurse Reviewer required.
  
• 1+ years of Utilization Management/ Prior Authorization Review experience required.
  
• Have access means of transportation for work away from the primary office 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 and continual updates to knowledge base regarding the codes.
  
• Medical Terminology.
  
• Medi-Cal and Medicare benefits and regulations.
  

Benefits

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

Competitive pay & weekly paychecks

Health, dental, vision, and life insurance

401(k) savings plan

Awards and recognition programs

Benefit eligibility is dependent on employment status.

Sunshine Enterprise USA is an Equal Opportunity Employer Minorities, Females, Veterans and Disabled Persons"