Nursing Jobs in Bell Gardens, CA
$88,854 - $142,166 / year
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. Job Summary The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)American Case Management Association (ACM)Required Training Physical Requirements LightAdditional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. Salary 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) 
$128,500 - $298,100 / year
Description Under the direct supervision of the Clinical Director, the Clinical Nurse Manager independently coordinates all outpatient services for the Department of Head and Neck Surgery. The nurse manager’s responsibilities include direct supervision of all clinical and back-office staff at the Westwood campus: NPs, RNs, LVNs, medical assistants, sterile processing technicians, scribes, and hospital lab technicians at all departmental sites, including developing and coordinating work schedules, taking disciplinary actions when needed, and completing annual performance evaluations. This role includes active participation in budget planning and management, decision about medical and surgical equipment acquisition (and assist with maintaining service contracts), and maintenance of complete and accurate charge documents and charge capture and provide oversight, within EMR (EPIC/CareConnect) while identifying areas of improvement. The Clinical Nurse Manager takes a lead role in performance improvement activities and patient satisfaction initiatives; ensures quality patient care is provided in accordance with UCLA policies and procedures, JCAHO, Title 22, OSHA, and DHS standards; runs weekly and monthly reporting on clinic staffing, productivity metrics, budget adherence, patient volumes, and others and report weekly utilizing Microsoft Office and EMR to Clinical Director. The position also develops and maintains all SOPs/competencies for all the clinical staff in the Department of Head and Neck Surgery. This position will require occasional (approx. 1x/month) travel to community Head and Neck sites with Clinical Director for site visits. Salary Range: $128,500 - $298,100 annually 
$88,854 - $142,166 / year
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. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)Required Training Physical Requirements LightAdditional Information May work on occasional weekends and some holidays depending on business needs. Salary 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) 
