Nursing Jobs in Chino Hills, CA
$63,897.60 - $83,075.20 / year
Overview: What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Claims Review Nurse, LVN identifies process improvements in the UM/Claims interface and makes recommendations to improve the claim authorization process and business rules between Claims and UM teams. The Claims Review Nurse, LVN exercises independent judgment in conducting claims reviews and supports key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits: Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account – Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities: Audit medical necessity claims in accordance with departmental policies and procedures Act as the key clinical interface between the Claims and Medical Services departments Attend UM and Claims team meetings Review inpatient and outpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirements Obtain the appropriate clinical information necessary to make authorization decisions for unauthorized claims Identify potential denied services/admissions/days and present to the Medical Director, both Plan and Direct, for appropriate decision/direction Review medical records to determine if charges and/or services are appropriate (e.g., reviewing CPT/HCPCS codes, up-coding practices, and similar items) Analyze level of care on in-patient reviews. Track trends in billing patterns by provider and report to leadership practices that may need further investigation Develop and sustain positive working relationships, collaborating with physicians, nurses, ancillary personnel and all others as appropriate to promote open communication channels, obtain/disseminate information, and enhance customer relations Inform appropriate staff for coordination and negotiation of financial arrangements for non-contracted and/or fee-for-service providers and facilities Provide reports as necessary Adapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environment Perform any other duties as required to ensure Health Plan operations and department business needs are successful Qualifications: Education & Experience A minimum of one (1) year of relevant work experience Recent experience with inpatient and outpatient utilization and case management required Experience in auditing claims Experience in reviewing inpatient medical records and claims preferred Experience in managed care, MediCal, Medicare preferred High school diploma or GED Associate’s degree in health care or a related field from an accredited institution Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required Key Qualifications Knowledge and understanding of: CPT, ICD-10, HCPCS and hospital revenue codes Nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo) Medi-Cal, Medicare and other state/federal Program & Regulations Foundations of nursing practice and clinical pathways across inpatient, outpatient, and post‑acute settings Health plan policies, prior authorization protocols, appeals processes, and denial management Proficient in computer applications such as Word and Excel Skilled in Data Entry Skilled clinical review and judgement Data analysis and trend identification skills Communication skills (both written and verbal) Proven ability to: Exercise sound clinical judgement with minimal supervision Escalate appropriately to Medical Director for complex determinations Build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel Navigates diverse perspectives Adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality Handle PHI with strict adherence to privacy and security standards; maintains ethical audit practices Possess a strong attention to detail with the ability to multi-task Start your journey towards a thriving future with IEHP and apply TODAY ! Work Model Location: Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range: USD $63,897.60 - USD $83,075.20 /Yr. 
$125,000 - $187,582 / year
Position: Cardiac Advanced Practice Provider Monogram Health is seeking a Cardiac Advanced Practice Provider for the delivery of personalized, compassionate medical care to patients primarily with heart failure and other cardiac conditions. The Advanced Practice Provider will be responsible for caring for patients, maintaining accurate and current patient records and scheduling, administering follow-up appointments as required, and supporting the training and clinical readiness of local market APPs caring for patients with cardiac conditions in the home. The successful candidate will work as a team with our physician specialists, field-based nurses, community health workers, and physicians to deliver premium care to every patient. Primary duties include patient health assessment, creating strategies to improve or manage a patient’s cardiac condition, introducing habits for health promotion, and helping local market clinicians apply evidence-based cardiac care practices in the in-home setting. He/she may also conduct physical exams, order tests, prescribe medications, and serve as a coordinator with the patient's primary healthcare provider and their specialists. This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state. Compensation The base salary ranges for this role are listed below by state and reflect the range of experience and qualifications we may consider. Final compensation will be determined based on geographic location and job-related factors such as experience, skills, education, certifications, and internal compensation considerations. While a larger range is posted, most offers will typically fall within a narrower band based on these factors. In addition to base salary, this role is eligible for additional compensation, including bonus opportunities and a comprehensive benefits package. Arizona: $125,000 - $162,000 California: $133,250 - $173,225 Washington: $138,375 - $187,582 Responsibilities Work with stage 3 and 4 heart failure patients to ensure medication compliance, monitoring dietary and lifestyle changes, regular follow ups and care coordination. Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first. Work collaboratively with the Cardiologist and staff to provide high quality, patient centered care. Train, mentor, and support local market APPs in the assessment, management, and follow-up of patients with heart failure and other cardiac conditions in the in-home care setting. Develop and reinforce practical training on cardiac condition recognition, escalation criteria, medication management, patient education, care coordination, and documentation standards for local market APPs delivering home-based care. Partner with cardiology leadership and local market clinical teams to identify education needs, close knowledge gaps, and promote consistent application of evidence-based cardiac protocols across markets. Work closely with cardiology team, other specialist teams, and clinical care teams. Conduct assessments on patients both in the patients' home and in the virtual environment. Counsel and educate patients and families about benefits and programs available to help them live healthier lives. Document items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan. Complete all documentation and paperwork in a timely manner. Maintain quality of care standards as defined by the practice. Prescribe medications, order tests, and collaborate with patient’s Monogram cardiologist and physician. Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily. Assist patients with enrolling to access educational videos. Participate in the integrated care team meetings. Make assessment of patient's health status. Develop treatment plan. Implement a plan consistent with appropriate plan of care. Follow-up and evaluate patient's status. Position Requirements Active and unrestricted Registered Nurse and Nurse Practitioner license in one of the following states: AZ, CA, or WA or able and willing to obtain multiple state licenses. Board certified by ANCC or AANP. Current and unrestricted DEA certificate. Minimum of two (2) years of experience as an NP working in an inpatient or outpatient cardiology setting, required (please no new graduates) Ability to work without direct supervision and practice autonomously. Access to transportation, valid driver's license, and car insurance. Must be proficient with medical instruments and equipment required by the work. Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology. Ability to communicate effectively, in verbal and written form, with retail and medical partners at various levels, patients, family members, physicians and representatives of the community. Sound understanding of all federal and state regulations including HIPAA and OSHA. Background in patient assessment, diagnosis, treatment, and management of cardiac diseases Demonstrated communication skills, works well in a team environment, and is adaptable. Experience educating, coaching, or precepting APPs or clinical teams on cardiac disease management, preferred. Benefits Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts Financial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resources Time Off & Leave – 20 PTO days, 7 paid holidays, and 1 floating day to make your own, and paid parental leave Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts About Monogram Health Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. #LI-AW1 
