L.A. Care Health Plan
Location
Los Angeles, California
Salary
$88,854 - $142,166 / YEAR
The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals, ensuring timely determination and notification of referral statuses, and generates necessary approval or denial communications. This role also involves performing telephonic and/or onsite admission and concurrent review, collaborating on discharge plans, and monitoring inpatient admissions.
Candidates must possess at least 5 years of varied RN clinical experience in an acute hospital setting, including a minimum of 2 years in Utilization Management or Case Management within a hospital or HMO setting, and hold an active, unrestricted California Registered Nurse license. Required education is an Associate's Degree in Nursing, though a Bachelor's Degree is preferred, alongside strong computer literacy and excellent communication skills.
$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.
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.
Facilitates 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 Nursing
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.
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.
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.
Proven ability to lead successful performance improvement projects.
Registered Nurse (RN) - Active, current and unrestricted California License
Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
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