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This role will promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to denials. This role will review for appropriate care and setting, and follow guidelines/policies as they relate to the review process. It will be responsible for processing denial letters for all affiliated groups, interpreting denial language provided by the prior authorization nurse, coordinators, and medical directors, and placing it into the appropriate templates while translating medical terminology into lay language and grading the reading level as appropriate. Collaboration with department coordinators for clinical guidance on denial cases is essential.
Essential Duties and Responsibilities include:
- Understand all aspects of Access Express concerning prior authorization and denials.
- Complete assigned tasks accurately and within specified time limits.
- Maintain smooth working relations with co-workers and supervisors,



being a “Team Player”.
- Anticipate future events, set realistic goals, timetables, and coordinate activities to ensure smooth workflow and time management.
- Understand, promote, and review the principles of medical management to facilitate appropriate care.
- Understand all Regal Medical Management policies and procedures.
- Communicate effectively with department managers, nurses, coordinators, regional medical directors, and staff regarding denials processes.
- Speak concisely and tactfully on all subjects related to Denials.
- Maintain relationships with denials coordinators, prior auth teams, pharmacy, medical directors, and network management.
- Maintain regulatory Turnaround Time Standards per guidelines.
- Document all necessary information accurately in authorization notes.
- Communicate with prior auth teams and medical directors for denials needing clarification, providing

📌 Nurse Trainer, Utilization Management (Lima)
🏢 Regal Medical Group
📍 Lima