Nursing Jobs in Rossmoor, CA
$123,000 - $145,000 / year
Nurse Practitioner / Physician Assistant - Hybrid (Harris County, TX) Department: Quality - Risk Adjustment Ops Employment Type: Full Time Location: 568 W. Garvey Ave, Monterey Park, CA 91754 Compensation: $123,000 - $145,000 / year Description We are looking for a motivated Spanish and/or Tagalog speaking Nurse Practitioner / Physician Assistant to join a team that is passionate about improving the health of our patients. As part of the Quality Department, the Clinical Operations team leads the effort to improve health outcomes through proactive outreach, preventive care, and patient education. Together, we empower patients to take an active role in managing their health and chronic conditions while advancing healthier communities across all stages of life. This is a unique opportunity to play an instrumental role in the expansion of our Annual Wellness Visit (AWV) program throughout the Houston market. As one of the first providers supporting this initiative in the region, you will help establish a strong foundation for patient engagement, preventive care delivery, and quality outcomes while partnering closely with clinical and operational leaders as the program grows. In this hybrid role, you will conduct 5 to 6 Annual Wellness Visits (AWVs) per day across Harris County, meeting patients where they are, primarily in their homes or local care facilities, or 10 to 11 AWVs per day via telemedicine. These visits serve as critical touchpoints to assess patients' current health status, identify and address risk factors, and support long-term wellness planning. You will review and update medical histories, evaluate health risks, and recommend appropriate preventive services. Through close collaboration with patients, you will play a key role in influencing health behaviors and driving improved outcomes over time. 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 Conduct 5-6 Annual Wellness Home Visits per day within the Harris County, TX area Conduct 10-11 Annual Wellness Telehealth Visits per day across Astrana Health’s covered markets Document chief complaint, previous medical, family, and social history, review of systems, examination, assessment, and appropriate plan of care Identify gaps in care during the evaluation that may require additional screening, diagnostics, and laboratory studies Recapture previous conditions while carefully capturing newly found conditions Create or update a Personalized Prevention Plan based on current health and risk factors to optimize the management of current conditions and prevent illnesses Provide patient education regarding preventive services and prescribed treatments, reinforce the importance of staying current on covered preventive services Make recommendations for member's follow-up with their primary care physician Communicate with AWV Care Coordination team to ensure patients receive necessary referrals to additional services Complete documentation/charting in an accurate and timely manner Comply with federal, state, and local legal and professional requirements by studying existing and new legislation, anticipating future legislation; enforcing adherence to requirements; advising management on outstanding actions Other duties as assigned Qualifications Active and unrestricted Texas Nurse Practitioner (NP) or Physician Assistant (PA) license. Current national board certification (AANP, ANCC, or NCCPA, as applicable). Active DEA registration and NPI number. Valid Texas driver's license, reliable transportation, and ability to travel within the service area as needed. Minimum of one (1) year of direct patient care experience as a Nurse Practitioner or Physician Assistant in Primary Care, Geriatrics, Family Medicine, Internal Medicine, Home Visits or related setting. Experience using electronic health record (EHR) systems. Strong clinical assessment, documentation, and patient communication skills. You’ll be great for this role if you have: Experience with Medicare Advantage populations, Annual Wellness Visits (AWVs), and value-based care models. Knowledge of HEDIS, HCC coding, and quality measures. Experience working with ACO, IPA, managed care, or population health programs. Fluency in Tagalog and/or Spanish (preferred). Environmental Job Requirements and Working Conditions This is a full-time, hybrid position scheduled as four (4) - ten (10) hour shifts per week OR five (5) days - eight (8) hour shifts per week, serving patients throughout the Harris County, Texas territory. This position will work two days in the field and two days from home. Mileage reimbursement is included. The national target compensation target pay range for this role is between $123,000 - $145,000 annually. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors. Additional Information: Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request accommodation. The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change. 
$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) 
