Nursing Jobs in Rossmoor, 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 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) 
$145,000 - $155,000 / year
Nurse Practitioner - Cardiology (Cantonese/Mandarin Preferred) Department: Providers Employment Type: Full Time Location: 506 W. Valley Blvd. Unit #100, San Gabriel, CA 91776 Reporting To: Yih Kok Compensation: $145,000 - $155,000 / year Description Astrana Health is seeking a Cardiology Nurse Practitioner (NP) to join our Southern California Heart Center group in San Gabriel! The NP collaborates closely with supervising cardiologists and the interdisciplinary care team to provide high-quality, patient-centered care across clinic and hospital settings. This position entails working at our outpatient San Gabriel location and inpatient at Garfield Medical Center, Alhambra Medical Center, and San Gabriel Valley Medical Center. We are seeking candidates who are passionate about cardiology and providing patient-centered care! Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Clinical Care Perform comprehensive patient assessments, including history, physical examination, diagnostic interpretation, and formulation of differential diagnoses. Manage primary and secondary cardiovascular conditions under physician supervision, including preventive care, chronic disease management, and post-procedure follow-up. Participate in the evaluation and initial stabilization of acute or complex conditions, with timely physician consultation and escalation as appropriate. Order and interpret laboratory tests, imaging studies, and other diagnostic procedures consistent with clinical protocols. Perform approved procedures and minor interventions consistent with training, credentialing, and observed competency. Medication Management Prescribe, adjust, and discontinue medications in accordance with California PA regulations, supervising physician agreements, and clinic policies. Educate patients on medication use, risks, benefits, and follow-up requirements. Participate in controlled substance prescribing per practice protocols and applicable laws. Care Coordination & Documentation Maintain accurate, complete, and timely medical records in accordance with practice standards and regulatory requirements. Coordinate care with physicians, specialists, hospitals, and ancillary services. Participate in referrals, transitions of care, and follow-up planning. Supervision & Collaboration Work under the supervision of designated cardiologists. Collaborate with a team of advanced practice providers, nurses, medical assistants, technicians, and administrative staff to support efficient clinic and hospital operations. Assist in supervising delegated clinical tasks performed by medical assistants, consistent with scope and clinic policies. Quality & Compliance Participate in chart reviews, quality assurance activities, and performance evaluations. Adhere to all clinical policies, standardized procedures, and applicable federal, state, and local regulations. Support continuous improvement initiatives and evidence-based practice standards. Other duties as assigned. Qualifications Graduate of an accredited Nurse Practitioner program. Active, unrestricted California NP license. DEA registration (or eligibility to obtain). Prior cardiology or internal medicine experience preferred. Strong clinical judgment, communication skills, and ability to work in a fast-paced specialty practice. Bilingual Cantonese/Mandarin strongly preferred Environmental Job Requirements and Working Conditions This position is onsite, located at 506 W. Valley Ave, Unit #100, San Gabriel, CA 91776. NPs will also round at San Gabriel Valley Medical Center, Alhambra Medical Center, and Garfield Medical Center. This position will predominantly be M-F, 9 A - 5 P. NPs are expected to rotate weekend coverage. Our national target compensation for this position is $145,000 - $155,000 annually. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors. 
$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) 
