Utilization Management Clinical Quality Nurse Reviewer RN II
1 month ago
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role is ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position will focus on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and create reports on audit findings, as well as make recommendations, to submit to the department's Quality Assurance Team and UM Management.
DutiesFacilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines.
Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions.
Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation.
Works with department leadership to assess for all opportunities related to quality improvements.
Compiles and presents quality report cards that measure adherence to quality and regulatory compliance.
Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts.
Serves as a consultant to the organization's Compliance team on an ad hoc basis.
Performs other duties as assigned.
Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's DegreeMaster's Degree in NursingExperienceRequired:
At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation.
Preferred:
Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. Background in teaching and/or clinical education.
Required:
Superior verbal and written communication skills.
Advanced computer proficiency in both Microsoft Word and Excel.
Strong analytical and team building skills.
Ability to work independently and be self-directed.
Ability to work effectively with diverse team members.
Strong problem-solving skills.
Ability to multitask and streamline day-to-day operations.
Ability to translate regulatory requirements into auditable tools.
Preferred:
Proven ability to lead successful performance improvement projects.
Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional InformationSalary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
-
Utilization Management Nurse Specialist RN II
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeUtilization Management Nurse Specialist RN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11213 Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the...
-
Quality Management Nurse Specialist RN II
2 weeks ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Quality Management Nurse Specialist RN II is responsible for overseeing the clinical aspects of quality improvement projects and activities, which may include but are not limited to the clinical review process for potential quality of care and service issues, regulatory compliance with government agencies, and accreditation standards.Key...
-
Utilization Management Nurse Specialist RN II
4 weeks ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get...
-
Utilization Management Nurse Specialist RN II
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million...
-
Utilization Management Nurse Specialist RN II
3 months ago
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million...
-
Los Angeles, United States L.A. Care Health Plan Full timeClinical Assurance Compliance Nurse Specialist RN II Job Category: Clinical Department: Enterprise Performance Optimization Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11416 Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency...
-
Los Angeles, United States L.A. Care Health Plan Full timeClinical Assurance Compliance Nurse Specialist RN II Job Category: Clinical Department: Enterprise Performance Optimization Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11417 Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency...
-
Clinical Assurance Compliance Nurse Specialist RN II
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeClinical Assurance Compliance Nurse Specialist RN II Job Category: Clinical Department: Enterprise Performance Optimization Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11416 Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public...
-
Quality Management Nurse Specialist RN II
2 months ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make...
-
Quality Management Nurse Specialist RN II
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeJob Summary The Quality Management Nurse Specialist RN II is responsible for overseeing the clinical aspects for quality improvement projects/activities, which may include but are not limited to the clinical review process for potential quality of care and service issues, regulatory compliance with CMS, DMHC, DHCS, and NCQA. This position is...
-
Outpatient Utilization Management Coordinator II
2 weeks ago
Los Angeles, California, United States MedPOINT Management Full timeJob OverviewThe Outpatient Utilization Management Coordinator serves as the primary liaison between the Outpatient Utilization Management (UM) team and Health Plan representatives. This position is responsible for managing referral requests directed to Health Plans, including but not limited to tertiary care, durable medical equipment, and pharmacy services,...
-
Quality Management Nurse Specialist RN II
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million...
-
Case Manager Utilization RN
4 days ago
Los Angeles, California, United States Kaiser Permanente Full timeJob SummaryKaiser Permanente is seeking a skilled Case Manager Utilization RN to join our team. As a key member of our healthcare team, you will play a critical role in coordinating and managing the care of our patients.Key ResponsibilitiesCollaborate with Physicians: Work closely with physicians to develop and implement individualized plans of care that...
-
Clinical Assurance Compliance Nurse Specialist RN II
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members...
-
Utilization Management Nurse
5 days ago
Los Angeles, United States Presidential Staffing Solutions, LLC Full timeBenefits: 401(k) Competitive salary Dental insurance Health insurance Paid time off Signing bonus Training & development Vision insurance Outpatient Case Management West Los Angeles VAMC 11301 Wilshire Blvd Los Angeles, CA. 90073 There are five new RN vacancies at the West Los Angeles VA Medical Center. Service Line | Unit | Position Title | Tour | Qualified...
-
Enhanced Care Management Clinical Specialist II
4 weeks ago
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members,...
-
Clinical Assurance Compliance Nurse Specialist RN II
2 months ago
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make...
-
Clinical Assurance Compliance Nurse Specialist RN II
2 months ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get...
-
Utilization Management Nurse
1 week ago
Los Angeles, United States Presidential Staffing Solutions, LLC Full timeJob DescriptionJob DescriptionOutpatient Case ManagementWest Los Angeles VAMC11301 Wilshire BlvdLos Angeles, CA. 90073There are five new RN vacancies at the West Los Angeles VA Medical Center. Service Line | Unit | Position Title | Tour | Qualified Contractor | VendorHOSPITAL OPERATIONS | INPATIENT | RN | 0630-1500 | Vacant | OpenHOSPITAL OPERATIONS |...