Nursing Jobs in El Segundo, CA
$206,311 - $350,729 / year
Salary Range: $206,311.00 (Min.) - $278,520.00 (Mid.) - $350,729.00 (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 Medical Director, Utilization Management provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions. This position requires evaluation and insight for both medical and behavioral health cases. In this position, the Medical Director supports the development of and ensures the application of clinical policies are consistent with evidence-based medicine and regulatory requirements. The Medical Director collaborates with internal teams to support timely consistent and defensible clinical decisions and promotion of appropriate high-value care. In support of payment and program integrity initiatives, the Medical Director reviews clinical documentation to validate coding accuracy and appropriateness and completion of billed services. This position plays a critical role in the mitigation of Fraud, Waste and Abuse (FWA) and requires proactive analysis of service level utilization data to identify trends, outliers and emerging risk areas and recommend corrective action to minimize utilization variation, prevent improper payments and ensure financial stewardship. Works collaboratively with Health Services departments and key organizational stakeholders, to ensure alignment of utilization management, claims review, and regulatory compliance activities. Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals. Duties Provides physician leadership within the Health Services division, with primary responsibility for overseeing Utilization Management (UM) reviews, conducting medical claims review under Payment Integrity and supporting Behavioral Health (BH). Applies clinical expertise and evidence-based criteria to behavioral health and medical/surgical services, conducting claims reviews in compliance with regulatory timeframe requirements. Leads efforts to strengthen Payment Integrity by overseeing clinical validation of requested services, ensuring alignment between documentation and medical necessity. Analyzes utilization and claims data to identify trends, outliers, cost drivers, and opportunities to reduce unnecessary services and prevent improper payments. Identifies and mitigates Fraud, Waste, and Abuse (FWA) risks by detecting patterns, and partners with internal teams as appropriate. Develops, approves, and updates medical policies, procedures, and standards of care based on current, evidence-based practices. Oversees and reviews the delivery of patient care to ensure it meets quality standards and regulatory guidelines. Guides quality assurance and performance improvement (QAPI) programs and participates in quality review committees. Maintains and enforces compliance with all federal and state laws, accreditation standards (such as NCQA), and other regulatory requirements. Assists in the preparation and monitoring of departmental budgets, including managing costs and resource utilization. Performs other duties as assigned. Duties Continued Education Required Doctor of Medicine (M.D.) Education Preferred Experience Required: At least 8 years of experience in medical management, managed care and quality management. Experience in Payment Integrity. Experience in maintaining liaison with Federal, State, and local bodies and medical organizations. Experience in performance management and possession of strong analytic ability. Extensive post-medical degree experience in clinical practice. Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry. Proven experience in a physician leadership role, including managing teams. Preferred: Experience with Medicaid managed care and/or governmental programs for underserved, safety net populations including women, children, person with disabilities, seniors, and those of varied ethnic and cultural backgrounds. Skills Required: Ability to provide leadership to physicians, nurses, and other health care professionals, and an interest and involvement in the affairs of the health care community. Excellent written and verbal communication skills with the ability to effectively collaborate with multidisciplinary teams and senior leadership. Strong leadership, consensus-building, and stakeholder engagement skills, as well as a commitment to evidence-based practice, continuous quality improvement, regulatory compliance, and health equity. Demonstrated ability for teamwork and collaborative problem-solving. Commitment to patient-centered, value-based care. Strong leadership presence with the ability to lead, mentor, and motivate a team. Exceptional presentation skills to effectively convey complex medical concepts to diverse audiences. Ability to think strategically and take a broad, business-oriented perspective. Strong analytical and problem-solving skills, with a data-driven approach to evaluating programs. Ability to work in a fast-paced, dynamic, and often ambiguous environment. Licenses/Certifications Required Board Certified, preferably in Internal Medicine, Family Medicine, Emergency Medicine or Psychiatry. Clinical License to practice or an Administrative License to review Utilization Management cases. - Active, current and unrestricted California License Licenses/Certifications Preferred Certification as a Certified Medical Director (CMD) Required Training Physical Requirements Light Additional Information 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) $185,000 - $223,000 / year
Job Summary The Clinical Nurse Manager – Ambulatory Surgery Center (ASC), Pre-Admission Testing (PAT), GI Lab, and Central Scheduling is responsible for the operational, clinical, regulatory, and financial performance of these perioperative support and procedural areas. Reporting to the Director of Perioperative Services, the Manager provides leadership to ensure safe, high-quality, efficient patient care delivery across ambulatory procedural services and perioperative preparation workflows. The Manager oversees daily operations, staffing, regulatory compliance, patient throughput, scheduling processes, quality improvement initiatives, and staff engagement while fostering a culture of accountability, collaboration, and service excellence. This role collaborates closely with surgeons, anesthesia providers, nursing leadership, and scheduling teams to optimize procedural access, improve patient preparedness for surgery, and ensure efficient coordination of care throughout the perioperative continuum. Major Responsibilities / Essential Functions Clinical Operations & Procedural Oversight (25%) • Manages day-to-day operations of ASC, PAT, GI Lab, and Central Scheduling. • Ensures delivery of safe, evidence-based care in procedural environments. • Coordinates patient preparation, procedural flow, recovery processes, and scheduling operations. • Monitors patient safety indicators and clinical outcomes in ambulatory procedural settings. Patient Throughput & Scheduling Coordination (20%) • Oversees Central Scheduling operations to ensure efficient surgical and procedural scheduling. • Coordinates scheduling workflows with surgeons, physician offices, and perioperative departments. • Monitors scheduling accuracy, case readiness, and patient preparation timelines. • Works with PAT to reduce day-of-surgery cancellations and delays. Quality Improvement & Regulatory Compliance (15%) • Maintains regulatory readiness for Joint Commission, CMS, and CDPH requirements. • Ensures compliance with infection prevention, patient identification, and procedural safety standards. • Monitors quality indicators including same-day procedure cancellations and patient preparation compliance. • Leads performance improvement initiatives based on quality and operational metrics. Workforce Leadership & Staff Development (20%) • Manages hiring, onboarding, performance evaluations, and corrective action processes. • Develops staffing plans aligned with procedural volume and patient acuity. • Ensures competency validation for nurses and procedural staff. • Promotes professional development and certification attainment. Financial Stewardship & Resource Management (10%) • Assists in development and monitoring of departmental budgets. • Monitors productivity, staffing utilization, overtime, and premium pay. • Supports supply management and cost containment initiatives. Interdisciplinary Collaboration & Physician Partnership (10%) • Collaborates with surgeons, gastroenterologists, anesthesia providers, and physician offices. • Facilitates communication between procedural departments and surgical services. Job Qualifications Minimum Education • Bachelor of Science in Nursing (BSN) required. Preferred Education • Master’s degree in Nursing, Healthcare Administration, Business Administration, or related field preferred. Minimum Experience • Minimum 3–5 years acute care nursing experience. • Minimum 2–3 years nursing leadership experience. • Experience in perioperative services, ambulatory surgery, procedural services, or GI/endoscopy required. Required Licensure & Certifications • Current California Registered Nurse (RN) License • Basic Life Support (BLS) – American Heart Association • Advanced Cardiac Life Support (ACLS) – American Heart Association • NE-BC (Nurse Executive – Board Certified) required within 12 months of hire • CNOR, CGRN, CAPA, or CPAN certification preferred • Los Angeles County Fire Card within 30 days of hire • Assault Response Competency (ARC) within 30 days of hire Compliance, Service & Safety Consistently supports compliance with the organization’s Code of Conduct, maintains confidentiality of information, protects organizational assets, and adheres to all federal, state, and local regulatory requirements. Managers are accountable for communication, implementation, monitoring, and enforcement of compliance policies within their departments while promoting a safe and respectful work environment. Full-Time, Exempt 