Nursing Jobs in Malibu, 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 Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. 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 varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. 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) 
$160,000 - $190,000 / year
About Atria: Atria is a membership-based preventive health care practice delivering cutting-edge primary and specialty care from the comfort of your home, at our practices in Palm Beach and New York, or wherever you are in the world. We bring together a multidisciplinary team of renowned, in-house physicians to provide proactive, preventive, and precision-based care for Atria members and their families. We aim to optimize the lifespan and healthspan of all our members through meticulous screening and tailored interventions to prevent, reverse, or manage all major chronic diseases. Each member’s care is led by a dedicated Chief Medical Officer who collaborates on your behalf with specialists in cardiology, neurology, pediatrics, gynecology, endocrinology, performance and movement, and more. Our exceptional clinicians also work closely with the 60+ members of the Atria Academy of Science & Medicine, top experts in their respective fields who are available for rapid consults, support, and referrals. As a nurse practitioner in pediatrics at Atria, you will: Partner with Atria pediatricians to provide exceptional care in a state of the art facility, as well as providing care to our members in the comfort of their homes. Work collaboratively with Pediatricians to provide Preventive Care, Well Visits & Personalized Health Assessments and independently with direct and indirect supervision for urgent visits and focused follow up. Perform minor procedures such as insertion of a peripheral IV, phlebotomy, wound care and vaccinations. Correspond with families in writing via secure message and email and in collaboration with care coordination team. Flexibility to work weekends and off hours for on-call coverage for home care visits and Institute coverage, as necessary Provide occasional nursing tasks for adult patients, for example doing a flu vaccination for the parent of a child. Who You Are: You are a compassionate Pediatric NP who enjoys close relationships with families and demonstrates exceptional communication skills in person, by phone and electronic messages. You are a team player who will thrive in a collaborative environment including administrative support, pharmacy, nutrition, coaching and other providers. You have fluency with primary care guidelines and a love of learning. Compensation: $160,000 - $190,000 Current California License with nurse practitioner credential in Pediatrics or Family 2+ years’ Pediatric experience as NP National Board Certification as NP (Pediatrics or Family) BLS certification from American Heart Association Capable and experienced with relevant procedures including but not limited to vaccination, phlebotomy, catheterization, intravenous line placement, medication administration by IV, IM and nebulizer Adaptability to gain training and demonstrate competencies in a variety of point of care testing modalities and devices Must possess reliable transportation, a valid driver’s license, and the ability to travel to and from member home visits within the assigned service area At Atria, we are proud to offer every member of the Atria team: Excellent health and wellness benefits, fully covered by Atria, effective date of hire OneMedical membership for employees & dependents, giving access to 24/7 virtual care Fertility & family planning Company-covered preventive health screenings through partner hospitals (calcium score) Fitness Perks, including Wellhub + 401k contributions and 4% match starting after 6 months Flexible Time Off Continuing medical education (CME) and CEU support for professional licensure Time to give back and make an impact in underserved communities 
