Nursing Jobs in Downey, 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 Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the day-to-day clinical operations of the A&G department, and monitoring the A&G RN staff responsibilities and activities. This includes, but is not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolutions within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Appeals & Grievances and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible for assisting with and development and maintenance of a successful and cohesive unit, with a high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the A&G department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A Care's culturally diverse membership. The position supports the A&G Clinical Manager. This role also assists the A&G Leadership in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of A&G staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors staff’s performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the A&G team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees A&G clinical activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Duties Continued Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Fosters a culture that encourages employee contribution to ensure the department maintains an environment in which quality flourishes. Serves as a member/resource/liaison to the A&G Operations Team. Recommends resources to improve performance standards in terms of Appeals & Grievances. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 8 years of RN acute/clinical care experience. At least 2 years in a lead/supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Preferred: Previous experience in Medicare/ Medicaid in a managed care/ health plan environment.Skills Required: Knowledge of state, federal and regulatory requirements in Appeals/Care/Case/Utilization Management/Quality. Strong verbal and written communication skills. Computer literacy with proficiency in Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, 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) 
$84,067 - $163,931 / year
JOB DESCRIPTION Candidates must hold a current California license , reside in the San Diego, California area , and be able to travel up to 10% as required. The ideal candidate will have 2 to 3 years of leadership experience within a managed care organization , with a proven ability to lead teams, drive performance, and support member-centered care initiatives. Strong leadership, collaboration, and operational management skills are essential to successfully advance care delivery goals and improve member outcomes. The successful candidate will ensure members achieve optimal health outcomes through the integrated delivery and coordination of care across the continuum while contributing to organizational strategies that promote high-quality, cost-effective care. Job Summary Leads and manages a multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Oversees team performance for one or more of the following healthcare services functions: care management, utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), transition of care, behavioral health, long-term services and supports (LTSS), and/or special programs. • Facilitates integrated, proactive healthcare services management - ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina clinical model. • Functions as a “hands-on” leader - assisting with assessing and evaluation of systems, day-to-day operations and efficiency of services/care delivery. • Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators. • Assists in implementing care management, utilization management, behavioral health, care transitions, LTSS and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Ensures delivery of member care and services are aligned with Molina's established standards of customer service excellence. • Ensures high-risk, complex members are adequately supported. • Oversees ongoing monitoring of performance, protocols and guidelines related to healthcare services. • Collaborates with and keeps senior level healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Performs and promotes interdepartmental/multidisciplinary integration and collaboration to enhance continuity of care. • Oversees interdisciplinary care team (ICT) meetings. • Analyzes and reports on care access and monitoring statistics including plan utilization, staff productivity, cost-effective utilization of services, management of targeted member population, and triage activities. • Ensures completion of staff quality audit reviews evaluates services provided, outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost-effectiveness and compliance with all state and federal regulations and guidelines. • Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate. • Identifies opportunities for care delivery/quality/operational/etc. process improvements. • Hires, trains, develops and manages team demonstrates accountability for team performance and achievement of department-specific goals. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 7 years of health care experience, including at least 3 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or special programs, or equivalent combination of relevant education and experience, or equivalent combination of relevant education and experience. • At least 1 year of management/leadership experience. • Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Strong customer service skills/member-centric focus. • Ability to work within a variety of settings and adjust style as needed, including ability to work with diverse populations, various personalities and personal situations. • Ability to prioritize and manage multiple deadlines. • Strong organizational and problem-solving skills. • Ability to collaborate cross-functionally within a highly matrixed organization. • Strong written and verbal communication skills. • Microsoft Office suite and applicable software program(s) proficiency. Preferred Qualifications • Clinical experience. • Registered Nurse (RN) or master's level behavioral health (BH) licensure. License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $84,067 - $163,931 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 
$84,067 - $163,931 / year
JOB DESCRIPTION Candidates must hold a current California license, 2-3 years case management exprience reside in the San Diego, California area , and be able to travel up to 10% as required. The ideal candidate will have at least 2 to 3 years of leadership experience within a managed care organization , with a proven ability to lead teams, drive performance, and support member-centered care initiatives. Strong leadership, collaboration, and operational management skills are essential to successfully advance care delivery goals and improve member outcomes. The successful candidate will ensure members achieve optimal health outcomes through the integrated delivery and coordination of care across the continuum while contributing to organizational strategies that promote high-quality, cost-effective care. Job Summary Leads and manages a multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Oversees team performance for one or more of the following healthcare services functions: care management, utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), transition of care, behavioral health, long-term services and supports (LTSS), and/or special programs. • Facilitates integrated, proactive healthcare services management - ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina clinical model. • Functions as a “hands-on” leader - assisting with assessing and evaluation of systems, day-to-day operations and efficiency of services/care delivery. • Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators. • Assists in implementing care management, utilization management, behavioral health, care transitions, LTSS and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Ensures delivery of member care and services are aligned with Molina's established standards of customer service excellence. • Ensures high-risk, complex members are adequately supported. • Oversees ongoing monitoring of performance, protocols and guidelines related to healthcare services. • Collaborates with and keeps senior level healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Performs and promotes interdepartmental/multidisciplinary integration and collaboration to enhance continuity of care. • Oversees interdisciplinary care team (ICT) meetings. • Analyzes and reports on care access and monitoring statistics including plan utilization, staff productivity, cost-effective utilization of services, management of targeted member population, and triage activities. • Ensures completion of staff quality audit reviews evaluates services provided, outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost-effectiveness and compliance with all state and federal regulations and guidelines. • Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate. • Identifies opportunities for care delivery/quality/operational/etc. process improvements. • Hires, trains, develops and manages team demonstrates accountability for team performance and achievement of department-specific goals. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 7 years of health care experience, including at least 3 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or special programs, or equivalent combination of relevant education and experience, or equivalent combination of relevant education and experience. • At least 1 year of management/leadership experience. • Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Strong customer service skills/member-centric focus. • Ability to work within a variety of settings and adjust style as needed, including ability to work with diverse populations, various personalities and personal situations. • Ability to prioritize and manage multiple deadlines. • Strong organizational and problem-solving skills. • Ability to collaborate cross-functionally within a highly matrixed organization. • Strong written and verbal communication skills. • Microsoft Office suite and applicable software program(s) proficiency. Preferred Qualifications • Clinical experience. • Registered Nurse (RN) or master's level behavioral health (BH) licensure. License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $84,067 - $163,931 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 
