Nursing Jobs in Central LA, CA
$102,183 - $163,492 / year
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (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 Lead Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit. This position is responsible for the quality review of complex and/or escalated clinical A&G cases for all lines of business (LOB). The Lead will assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines. Leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion. Duties Review and process complex and/or escalated clinical A&G cases. Analyze the patient medical records, clinical documentation, and insurance policies to determine medical necessity. Prepares and reviews A&G files for submission to providers and internal departments. Work with other departments to ensure all aspects of a case are appropriately managed. Conduct targeted and random clinical case audits to ensure that all regulatory and departmental guidelines, policies, procedures, and standards are met. Work closely with the leadership team to create and/or modify Desk Level Procedures and recommend enhancements to process and procedures. Assist the Clinical Supervisors in identifying deviations in performance and process changes are implemented to redirect performance to acceptable levels. Recommend and implement resolutions, new processes, and/or process improvement. Provide accurate and timely written statistical reports that include historical and/or current data to aid in projecting or evaluating compliance status. Identify and analyze trends in appeals and grievances to find the root cause of denials. Duties Continued Check, verify and ensure that all clinical A&G cases are processed accurately and within established timelines to meet or exceed member satisfaction goals and regulatory (CMS, DMHC, DHCS, NCQA), Health and Safety Code and company compliance. Maintain documentation of all communications in the A&G system to ensure thorough tracking of case status. Lead the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Work closely with management to review performance and quality standards on an ongoing basis. As well as motivational programs needed to achieve regulatory standards. Act as a back-up to the Supervisor in leading meetings and handling escalations as required. Perform other duties as assigned. Education Required Associate's Degree in Nursing for Registered Nurses Education Preferred Bachelor's Degree in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting, At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment. At least 1 year of leading a process, program, or staff experience. Preferred: Clinical acute experience. Skills Required: Extensive knowledge of healthcare regulations and managed care guidelines Demonstrated ability to provide recommendations towards resolution. Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity. Ability to communication, conflict resolution, and motivational skills. Ability to work independently and closely with a team in a collaborative and interactive environment. Ability to adjust to changing circumstances within the team. Good verbal and written communication skills. Preferred: Strong project management skills with the ability to manage multiple training initiatives simultaneously. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, and occasional flexibility in hours/shift in critical situations and work on-call. This position requires handling various caseloads and flexibility to adapt to changing priorities, which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned. 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) 
$111,893 - $218,192 / year
Job Description Job Summary Supervises and mentors a team focused on primary, urgent, and preventative care services in various non-clinical community settings such as homes, nursing facilities, shelters, and pop-up clinics, in any environment where members feel most comfortable and are receptive to care that aligns with Molina Healthcare’s philosophy and mission. Provides direct medical care to all levels of patients and population groups, for example, adult, geriatric, pediatric and women’s health. Responsible for the day to day supervision of practitioners in assigned region(s). Works with the clinical leadership team to ensure practitioners are providing high quality care to patients and access to care is available to all patients. Provides real time training and mentoring to practitioners by rounding regularly and directly engaging in patient care. Provides education on clinical guidelines, coding, quality measures, and documentation excellence. Job Duties Provides evidence-based, high-quality patient care via in-person and telehealth visits based on clinical and business need. Leads a team of regional employees to ensure patient-focused and culturally sensitive medical care is delivered to patients. Travels to location of team members and performs hands on training, coaching, and mentoring of team in order to optimize performance and reach department and clinical goals. Performs performance management including coaching, monthly 1:1s, and end of year evaluations. Leads in the orientation of new practitioners and mentors new employees with hands on training and support via ride along for member visits. Performs and coordinates alternating on-call coverage to triage any urgent lab results or clinical needs and develop appropriate plan of care. Participates in the implementation of new clinical projects and onboarding staff. Using evidence-based guidelines, properly diagnoses and creates patient-focused plan of care and treatment. Orders/performs pertinent diagnostic laboratory and radiology testing, prescribes medication and durable medical equipment, and places referrals as clinically appropriate. Documents thoroughly and accurately in electronic medical records with a focus on ensuring continuity of care while complying with Health Insurance Portability and Accountability Act (HIPAA). Collaborates with other teams and leads direct reports with the goal of clinical outcomes, clinical documentation excellence, and exceeding department goals. Addresses chronic and acute primary care complaints, ascertains medical urgency, and takes appropriate action based on evidence-based guidelines. Seeks specialty consultation as needed. Carries up to 50 lbs. of equipment daily. Equipment can be transported using a backpack or a rolling bag, depending on preference. Participates in community-based initiatives geared towards building relationships with the community while addressing gaps in health care, such as pop-up clinics and shelters. Drives up to 120 miles a day on a regular basis to a wide variety of locations within the assigned region(s) with potential for additional mileage on extended mileage days or special project days. Actively participates in and leads regional meetings hosted by managers, peers, senior leadership team and other department leads including workshops, townhalls, huddles, new programs, new pilots, and initiatives. Job Qualifications REQUIRED QUALIFICATIONS: At least 3 years of experience as a nurse practitioner, or equivalent combination of relevant education and experience, including experience as a Nurse Practitioner with Molina. Active and unrestricted national certification from one of the following organizations: American Academy of Nurse Practitioners (AANP) or American Nurses Credentialing Center (ANCC). Current state-issued license to practice as a Family Nurse Practitioner (FNP). Current Basic Life Support (BLS) certification. Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements. Advanced computer skills. Proficient with Word, Excel, and Electronic Medical Record. Strong verbal and written communication skills. Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations. Ability to work independently, with minimal supervision and demonstrate self-motivation. Responsive in all forms of communication, and ability to remain calm in high-pressure situations. Ability to develop and maintain professional relationships with individuals. Excellent time management and prioritization skills; ability to focus on multiple projects simultaneously and adapt to change. Excellent problem solving and critical thinking skills. PREFERRED QUALIFICATIONS: Leadership experience. Home visit/Home health experience. Bilingual To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing Molina Healthcare offers a competitive benefits and compensation package Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $111,893 - $218,192 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 
