Nursing Jobs in La Mirada, 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 Managed Long-Term Services and Supports (MLTSS) Nurse Specialist RN II applies advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for L.A. Care members. Utilizes assessments, member-centered care planning, direct provider coordination/collaboration and psychosocial wraparound services to promote effective utilization of available Health Plan benefits including, but not limited to Community Based Adult Services (CBAS), Skilled Nursing Facility (SNF) services, Intermediate Care Facility for Developmentally Disabled (ICF/DD) services, CalAIM Community Supports, Palliative and Hospice Care. Scope of work includes care coordination functions and must adhere to regulatory mandates that apply to Utilization Management (UM) and Care Management (CM). This position is responsible for assessing, planning, coordinating, and monitoring care needs to ensure members receive high-quality, cost-effective care that promotes independence and quality of life. The MLTSS Nurse Specialist RN II conducts comprehensive health assessments and is a member of an interdisciplinary team that is key in identifying the physical, psychological and social needs of the member. The MLTSS Nurse Specialist RN II collaborates with Skilled Nursing Facilities (SNF), Intermediate Care Facility - Developmentally Disabled (ICF-DD), Community Based Adult Services (CBAS) Centers, Residential Care Facilities for the Elderly (RCFE), Preferred Provider Groups (PPG), CalAIM providers (i.e. Community Supports Vendors), Palliative and Hospice Care Providers and cross functional units to facilitate coordination of services. This position may require provider onsite visits as needed. Duties Responsible for performing assessments and clinical review of medical records to determine appropriate care including physical health, behavioral health, and social determinants of health needs for members referred to; MLTSS administered programs. Responsible for UM authorization functions for services requiring prior authorizations in a timely manner with adherence to regulatory requirements. Identify and address gaps in care or overutilization, including overlapping services. Engages with members by conducting telephonic nursing follow up and care coordination when necessary, including transitions of care for Long Term Care (LTC) and ICF/DD populations. Provides direction to non-clinicians who assist members with accessing services and arranges for all services required while coordinating with the health care team to eliminate duplication of services. Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for MLTSS and other programs. Establishes relationships with referral sources and community resources, such as external providers and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Performs oversight and monitoring of provider performance for adherence to regulatory standards and contractual agreements. Participate in provider audits and quality improvement initiatives. Partners with Provider Network Management (PNM) and participates in Joint Operations Meetings (JOM). Duties Continued Facilitates care coordination with and provides education on available services to internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach minimizes member confusion, and ensures the best care is delivered in the most appropriate setting. Documents accurately and comprehensively based on the standards of practice and current organization policies. Performs other CM and UM functions as assigned and as needed /required by L.A. Care, to maintain regulatory requirements and company objectives. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 3 years of clinical nursing experience in direct patient care, such as ambulatory care, home care, palliative care, hospice care OR experience in Utilization Review or Care Management will be considered in lieu of direct patient care that may include at least 2 years of relevant Licensed Vocational Nurse (LVN) experience in a UM or CM capacity substituted for 1 year of RN experience. Clinical experience working with individuals with chronic illnesses, comorbidities, and/or disabilities in a UM/CM environment. Preferred: Experience in utilization review, skilled nursing, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agencies. Skills Required: Excellent verbal and written communication skills; with effective charting practices. Excellent organizational, time-management and priority-setting skills. Strong clinical skills with a knowledge of care needs for elderly, disabled, and/or frail populations and has applied knowledge of End-of-Life care. Customer Service Skills: Provision of excellent customer service required due to frequent communication with providers, members and interdisciplinary team. Technical Skills: Must be computer literate and proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint, Teams). Ability to effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System. Ability to maintain strict member confidentiality and complies with all HIPAA requirements. Preferred: Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)Required Training Physical Requirements LightAdditional Information Required: Travel to offsite locations for work. 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) $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 Clinical Policy Nurse RN II is responsible for analytical research, trending, and assessment based on legislation, regulatory and accreditation requirements that impact claims, Utilization Management (UM) department and healthcare services policies. Reviews and analyzes clinical financial data to assess the effectiveness of existing and proposed policies to identify opportunities for improvement, cost containment, and quality enhancement. This position plays a key role in translating regulatory impacts into operational strategies and works collaboratively with internal and external stakeholders to ensure clinical policies support safe, effective, and compliant care delivery. Assists in development of policies and programs that improve health outcomes and target Fraud, Waste and Abuse (FWA). This position works cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The Clinical Policy Nurse II serves as a liaison to ensure the ongoing maintenance of clinical coding for the authorization matrix. Duties Assess federal, state, and local legislation, regulatory guidance, and health care policies to identify potential impacts on clinical practice, reimbursement and organizational operations that impact healthcare services policies. Review and interpret clinical, utilization, and financial data to identify trends, opportunities for policy improvement and cost-savings. Research, develop, and evaluate clinical and health policy designed to improve patient outcomes, detect and mitigate Fraud, Waste, and Abuse (FWA), and streamline organizational processes. Monitor the implementation of health programs, clinical initiatives, and community action plans to assess effectiveness, compliance, and impact on patient outcomes. Collaborate with internal stakeholders to evaluate utilization trends and anomalies and contribute to policy development aimed at improving efficiency and compliance identified during risk assessments. Prepare analytical reports, summaries, and analyses assessing policy performance, regulatory impact, and communicate insights and recommendations to stakeholders to drive evidence-based policy and impacted outcomes. Present findings, recommendations, and action plans to key stakeholders. Participate in work groups related to healthcare services clinical policies and procedures including efforts to improve department processes, as needed. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with active participation in state regulatory audits such as Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and/or National Committee for Quality Assurance (NCQA) audits. At least 1 year of experience in clinical health services policies with a managed care plan. Skills Required: Demonstrated strong reporting skills by preparing clear, concise reports and presentations that communicate findings and performance. Working knowledge of clinical policies. Strong analytical and critical thinking skills with the ability to interpret regulatory requirements and legislation. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong problem solving and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Understanding of the managed care industry and market conditions. 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) $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 Clinical Policy Clinical Coder RN II is responsible for analyzing, interpreting, and operationalizing medical and utilization management policies to ensure accurate coding, appropriate authorization requirements, compliant claims processing, and effective utilization oversight. This position serves as a key clinical and coding resource, translating medical policy requirements into diagnosis, procedure, and service code logic, including determining which codes require prior authorization. Conducts in-depth research and analysis of legislation and regulatory requirements, clinical outcomes, utilization, claims, and financial data to identify utilization trends, fiscal risk, and opportunities for policy enhancement and cost containment. This position works cross-functionally with internal teams to ensure policies are codified, consistently applied, and monitored through reporting and data analysis. This position collaborates closely with internal stakeholders and external entities to support standardized benefit administration, effective program implementation, and organizational compliance with state, federal, and accreditation requirements. Duties Translate approved clinical policies and utilization management criteria into clear, codified claims rules and system logic to support accurate claims adjudication. Develop, revise, and recommend clinical policies and internal utilization management criteria when standard clinical guidelines are insufficient to support appropriate decision-making based on codified claim rules. Assess the downstream claims impact of new or revised clinical policies prior to implementation and recommend configuration updates to mitigate operational or financial risk. Participate in validation of claims configuration changes to ensure policies are applied correctly and consistently across all lines of business. Monitor post-implementation claims activity to identify configuration issues, unintended denials, or payment discrepancies related to clinical policy application. Support remediation of claims configuration defects by identifying root causes and coordinating corrective actions with internal teams. Participate in and lead specialty and cross-functional workgroups and committees focused on healthcare services clinical policies, utilization management processes, strategic initiatives, policy governance, operational alignment, and continuous improvement efforts. Ensure timely dissemination of accurate and consistent policies and procedures across departments. Promote collaboration, engagement, and a positive work environment while supporting departmental initiatives and team-based activities. Manage assigned projects from concept through implementation, ensuring timelines, quality standards, and deliverables are met. Analyze and interpret medical and utilization management policies to identify applicable diagnosis, procedure, and service codes and determine authorization, pre-payment, or post-payment review requirements. Define and maintain code lists that require prior authorization or other utilization management controls based on clinical evidence, regulatory guidance, utilization trends, and financial risk. Duties Continued Collaborate with internal teams to ensure authorization requirements and coding logic are accurately configured in authorization and claims systems based on authorization matrix requirements. Support accurate claims processing by validating codified authorization and policy requirements are correctly applied and aligned with approved medical policies. Provide clinical and coding recommendations to support the development, revision, and implementation of new or updated medical and utilization management policies. Investigate and resolve coding and authorization related issues, including claim denials, coding edits, authorization discrepancies, and policy interpretation questions. Review and assess claims edits, authorization matrixes, and coding rules to identify root causes of errors or inconsistencies and recommend corrective actions. Ensure coding, authorization requirements, and claims-related guidance align with medical necessity criteria, benefit structures, and applicable state, federal, and regulatory requirements. Develop, review, and maintain reporting related to authorization required codes, approval and denial rates, utilization patterns, claims payment outcomes, and policy effectiveness. Prepare reports, summaries, and presentations and communicate findings, recommendations, and action plans to internal and external stakeholders. Analyze claims, authorization, and utilization data to identify trends, measure policy impact, and recommend opportunities for policy refinement, cost containment, or reduction of administrative burden. Monitor post-implementation performance of authorization-required codes and recommend additions, removals, or modifications to authorization requirements based on regulatory thresholds and utilization outcomes. Perform other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 8 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Experience with medical coding systems. Preferred: At least 1 year of experience in editing and writing clinical health services policies within a managed care health plan. Skills Required: Proficient with clinical policy through skills in literature searching and clinical research analysis based on the best available evidence. Working knowledge of clinical policies. Working knowledge of CPT/HCPC codes and claims. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong analytical, problem solving, and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Ability to identify discrepancies, assess risk, and recommend actionable solutions. Knowledge of medical coding systems, including ICD-10-CM, CPT, and HCPCS, and their application in authorization and claims environments. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Proficient in claims configuration, including claims adjudication workflows, configuration of claims edits and rules, and the translation of clinical and utilization management policies into system-based claims logic to support accurate, compliant payment outcomes. Understanding of the managed care industry and market conditions. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Professional Coder (CPC) 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) 
