Nursing Jobs in Hidden Hills, 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) 
Description Take on a key leadership role with UCLA Health. The Practice Manager for Iris Cantor Women's Health Center will oversee the business and patient care functions of the assigned UCLA Health Community Clinics. Reporting to the Regional Director and Assistant Director of Operations, you will s upervises the medical front and back-office staff and coordinate clinical services. You will also0 p rovide daily administrative and operational oversight and physical space management. Salary Range: $70,900 - $145, 200/hourly Description In this role you will provide direct patient care for diverse patient population. Work with clinic management, administration, faculty physicians, fellows, residents, medical students, and other clinical staff to include LVN’s and MA’s and ancillary personnel in providing total patient care, maintaining high standards of care, and recognizing normal and abnormal signs and symptoms of life threatening emergencies. You will coordinate and prioritize tasks and protocols established by the department and/or administration. Salary Range: $30.36 - $47.94/hourly Description Under the direction of the Regional Director, the Community Clinic Operations Administrator oversees the administrative and clinical support functions for the assigned Community Clinic. This role is responsible for ensuring an effective, compliant, and patient-centered operation through oversight of patient experience, access, financial performance, staffing, clinical quality, and operational execution. You will partner closely with physician leadership and operational stakeholders to support high-quality care delivery consistent with UCLA Health standards and CI-CARE values. Salary Range: $86,400 - $184,800/annual Description In this role, you will oversee the business and patient care functions of the assigned UCLA Health Community Clinics. You will s upervise the medical front and back office staff and coordinate clinical services and provide daily administrative and operational oversight and physical space management. Supervision is minimal. Relative guidelines and references are available however; interpretation and original problem solving are required. Assignments are given in terms of broad organizational goals and objectives. Goal attainment is reviewed with the Director of assigned practice on a regular basis through formal and informal discussions. Salary Range: $68,800 – $141,000 Annual Description In this position, you will participate in providing patient care in the ambulatory setting, recognizing normal and abnormal signs and symptoms and providing support during life threatening emergencies. You will perform basic administrative, clerical and technical supportive services as needed. Salary range: 27.24 - 35.94 Hourly 
