Nursing Jobs in Fullerton, 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 Clinical Quality Nurse Reviewer RN II, under the purview of the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position focuses on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and creates reports on audit findings, as well as makes recommendations, to submit to the department's Quality Assurance Team and UM Management. Duties Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines. Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions. Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation. Works with department leadership to assess for all opportunities related to quality improvements. Compiles and presents quality report cards that measure adherence to quality and regulatory compliance. Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts. Serves as a consultant to the organization's Compliance team on an ad hoc basis. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree Master's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation. Preferred: Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. Background in teaching and/or clinical education. Skills Required: Superior verbal and written communication skills. Advanced computer proficiency in both Microsoft Word and Excel. Strong analytical and team building skills. Ability to work independently and be self-directed. Ability to work effectively with diverse team members. Strong problem-solving skills. Ability to multitask and streamline day-to-day operations. Ability to translate regulatory requirements into auditable tools. Preferred: Proven ability to lead successful performance improvement projects. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred 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) 
$174,920 - $228,314 / year
Mission Heritage Medical Group is seeking a full-time nurse practitioner to join an established Critical Care Medicine in Mission Viejo, California. This role offers the opportunity to care for a high-acuity patient population with strong clinical support and access to on-site labs, diagnostics, and subspecialty consultation. The team values provider autonomy, allowing clinicians to independently manage patient care. Join this dedicated and collegial team in Southern California. Position Details: Full-time (1.0 FTE), inpatient setting Night shift, 3 days per week (12-hour shifts) 8:00 p.m. to 8:00 a.m. with rotating weekends No call responsibilities Team includes 6 physicians and 1 NP On-site labs and diagnostic, availability for sub-specialists for consultations Growth opportunity within the organization Compensation & Benefits: Compensation is between $174,920 and $228,314 per year The posted salary reflects the starting range of total compensation and may include productivity bonuses, incentives related to quality and performance, hospital/ED call stipends, extra shift incentives, and other forms of cash compensation as applicable to the position. In addition, providers typically receive a CME allowance and other benefits offered by their medical group employer. Please note that this salary range is provided in accordance with State law and is subject to variation due to the factors noted above. Qualifications & Requirements: ICU experience is preferred Critical Care experience is preferred but not required Adult-Gerontology Acute Care Nurse Practitioner license is required Where You’ll Work Mission Heritage Medical Group is a growing multi-specialty group serving south Orange County communities. More than 150 excellent physicians work as a team to provide personalized care through innovative programs. Highly regarded by the communities it serves, Mission Heritage Medical Group offers primary care and a wide range of specialty care, including women's health, cardiology, radiology and urgent care. Where You’ll Live Mission Viejo, one of the largest master-planned communities in the country, is in the Saddleback Valley of south Orange County, facing the Pacific Ocean to the west and high desert foothills to the east. Known for gorgeous homes built in harmony with the surrounding natural environment, the city features tree-lined streets, upscale shopping centers, the 125-acre Lake Mission Viejo, beautiful golf courses and hiking trails. Who You’ll Work For Providence is a nationally recognized, comprehensive healthcare organization spanning seven states with a universal mission — to provide compassionate care to all who need its services, especially the poor and vulnerable. Its 122,000-plus caregivers/employees (including 34,000 physicians) serve in 51 hospitals, more than 1,000 clinics and a comprehensive range of health and social services. Providence: One name, one family, one extraordinary health system. Equal Opportunity Employer including disability/veteran Job ID Number: 31123 Facility Name: Mission Heritage Medical Group Location Name: Mission Viejo Brand Name: Providence Provider Profession: Nurse Practitioner Medical Specialty: Critical Care Medicine Job Setting: Hospital Type of Role: Clinical Email: Michelle.Clark@psdrecruit.org Phone Number: (213) 669-6824 Schedule: Full Time Compensation: $174,920 - $228,314 Per Year CP: Yes CB: Yes NP: Yes HC: Yes IS: No YM: Yes J1: No H1B: No Let’s get in touch If you have questions about this specific job or others, I'm all ears. Send me a note and we'll be one step closer to the right opportunity. Michelle Clark Provider Recruiter (213) 669-6824 Michelle.Clark@psdrecruit.org Contact Me 
$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) Responsibilities What you will do as a Caregiver Enhance the lives of older adults by assisting them with mobility needs and daily living activities, including housekeeping, bathing, grooming, and routine personal tasks Work cooperatively with other talented team members to support and care for residents Receive on-the-job training and have opportunities for career growth and advancement Solve problems and exhibit ethical behavior Qualifications No experience needed. We will provide you with all the training you need! Apply today to join the Atria team. Atria is an equal opportunity employer committed to providing equal employment opportunities without regard to race, color, religion, sex (including pregnancy), sexual orientation, age, national origin, disability, genetic information, veteran status, or any other classification protected by applicable law. 
