Nursing Jobs in Poly High, CA
$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) 
$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 (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards. This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA). The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. Duties Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation. Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered. Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination. Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards. Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols. Collaborate with internal teams to support payment integrity initiatives. Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions. Maintain productivity and quality standards consistent with departmental expectations. Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability. Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements. 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 Provider Dispute Review (PDR) processes. Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes. Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring. Skills Required: Knowledge of medical necessity criteria, reimbursement principles, and managed care operation. Working knowledge of clinical policies. Working knowledge of CPT/HCPC Codes, and ICD-10. Proficient in claims processing systems and electronic medical record platforms. Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions. Strong verbal and written communication skills. Ability to work independently with a high degree of initiative, organization, and self-direction. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA). Understanding of the managed care industry and market conditions. High organizational and time-management skills. Preferred: Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued. Advanced knowledge of medical necessity criteria tools such as InterQual or MCG. Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations. 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) 
$120,000 - $130,000 / year
Allara is a comprehensive women’s health provider that specializes in expert, longitudinal care that supports women through every life stage. Trusted by over 60,000 women nationwide, Allara makes expert healthcare accessible by connecting patients with multidisciplinary care teams that have a deep understanding of hormonal, metabolic, and reproductive care. Allara provides ongoing support for hormonal conditions like PCOS, chronic conditions like insulin resistance, and life stages like perimenopause, helping patients see improved health outcomes . As one of the fastest-growing women’s health platforms in the U.S., Allara is bridging long-overlooked gaps in healthcare for women. The Opportunity We're hiring board-certified Nurse Practitioners who want to focus on what matters most: delivering exceptional care to women who have historically been underserved. To learn more about our mission and clinical approach, visit allarahealth.com . Location: Fully remote within the U.S. Your Impact Conduct thorough patient assessments and develop personalized treatment plans via video visits Collaborate with a multidisciplinary care team to deliver the highest standards of care Complete required trainings and uphold Allara's clinical policies, standards, and best practices Educate patients on preventive care and wellness using evidence-based strategies Maintain accurate, up-to-date patient records and complete charting in a timely manner Respond to patient questions and administrative messages with clarity and care Dedicate a full-time focus to patient care, including consultations and medical guidance, with prescribing when clinically appropriate Required Qualifications Certification: Active national board certification as a (WHNP, FNP, or similar). Experience: Minimum of 2 years of consecutive experience as a Nurse Practitioner specializing in women's health and treating chronic conditions such as PCOS, Endometriosis, Hypothyroidism, Hashimoto’s, Metabolic Syndrome, Menopause, Fertility, Postpartum, PMDD, and Obesity. Clinical Independence: Proven ability to function as an autonomous provider with strong diagnostic judgment and critical thinking skills Communication: Exceptional written and verbal communication, with an emphasis on compassion and clarity Webside Manner: A natural ability to build trust and connection with patients in a virtual setting Evidence-Based Practice: A genuine commitment to delivering care rooted in current clinical research Technical Proficiency: Comfortable working across multiple platforms including EMR systems, text expanders, Gmail, Google Calendar, Zoom, and scheduling tools Telemedicine Experience: Prior telehealth experience is a plus State License Requirements & Hiring Considerations: An active, unrestricted, and unencumbered professional license in at least one U.S. state is required. A note on state licensing: All active and pending licenses held at the time of application are collected and reviewed during our process. Hiring decisions reflect current state-level needs, which evolve over time. Applicants may not move forward immediately if there is no active need in their licensed states. We regularly revisit candidates as needs expand and when experience, licensure, and role requirements align. What Allara Offers Annual base salary range: $120,000 – $130,000, and can increase up to $172,500 - $182,500 through our incentive compensation program. Final base salary & incentive range is commensurate with years of relevant experience. Health and Wellness: Medical, dental, and vision benefits Future Planning: 401(k) plan Time Off: Annual vacation, sick days, and holidays CME: Annual stipend and dedicated PTO days Flexible Scheduling: Set your schedule within full-time hour requirements Malpractice Insurance: Comprehensive coverage provided at no cost to you Mission-Driven Work: Help transform the standard of care for women living with conditions that have historically been underdiagnosed and undertreated Collaborative Provider Network: Connect with and learn from a community of skilled, like-minded Allara clinicians Inclusive Culture: Join a supportive, diverse team that values innovation, equity, and belonging #LI-JB1 At Allara , we believe in celebrating everything that makes us human and are proud to be an equal-opportunity workplace. We embrace diversity and are committed to building a team that represents a variety of backgrounds, perspectives, and skills. We believe that the more inclusive we are, the better we can serve our members. We’re an Equal Opportunity Employer and do not discriminate against candidates or patients based on race, color, gender, sexual orientation, gender identity or expression, age, religion, disability, national origin, protected veteran status, or any other status protected by applicable federal, state, or local law. 
$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) 
$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 Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to members with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, Fee for services (FFS) Medi-Cal/Medicare, or commercial insurance. Duties Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department. Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements. Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identification of Expedited Cases and resolution within 72 hours. Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation. Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE). Process the case thru to effectuation and final case documentation in the A&G system of record. Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE). Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director. When necessary, outreaches to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps. In instances where necessary, sends written notifications to appropriate parties. All interactions including verbal outreach and written communication will be documented in the A&G system of record. Participates inter-rater reliability training and assessments. 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 RN. At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment. Skills Required: Excellent interpersonal and communication skills. Computer literacy and adaptability to computer learning. Time management and priority setting skills. Must be organized and a team player Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. Good working knowledge of regulatory requirements/standards. 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, 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) 
