Nursing Jobs in Sanger, 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 NursingEducation Preferred Bachelor's Degree in NursingExperience 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 LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)Required Training Physical Requirements LightAdditional 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) $91,249.60 - $120,910.40 / year
Overview: What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Supervisor, Grievance & Appeals, the Grievance & Appeals Nurse, RN (G&A Nurse, RN) is responsible for working directly with the IPAs, Hospitals, internal IEHP departments, and the Grievance team to ensure Grievance and Appeal cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations and NCQA. This position coordinates care, within the scope of their licensure, of members in conjunction with the member’s PCP and IPA and/ or IEHP Team Members to provide continuous Quality-Of-Care and assist in the development of quality initiatives. The incumbent serves as a resource person to IEHP personnel, as well as external practitioners and providers. When designated, the G&A Nurse, RN will also be responsible for triaging and assigning Grievance and Appeals cases to ensure timeliness and regulatory requirements are met. The G&A Nurse, RN will support appropriate Grievance case categorization inclusive of Quality of Care, identification of member harm, in addition to the completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS). Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits: Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary CalPERS retirement State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account – Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities: Serve as a subject matter expert for Grievance and Appeals (G&A) and IEHP departments and is a resource for clinical and non-clinical Team Members in expediting the resolution of outstanding issues. Work closely with the Grievance & Appeals Team under the direction of the Grievance Nurse Leadership with Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/DHS/CMS to ensure all member grievance issues are investigated, and care is coordinated appropriately and in adherence to Grievance and Appeals Policies and Procedures. Directly communicate with IEHP Medical Directors. Resolve medical grievance and appeal cases, in conjunction with IEHP staff, Grievance Management, and Providers, as applicable. Responsible for initial medical review and clinical oversight of all received team cases. Triage new cases to identify medical urgency, Member Harm, appropriate reporting (e.g. APS & CPS) and the potential need for Organizational Determination and notify the Immediate Needs team to ensure timely resolution. Review Grievance & Appeal case categorization and classification to ensure it is accurate, assist in the resolution of member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the member’s care. Comply with mandated reporting obligations and serve as the first line to report allegations of physical and sexual abuse to the appropriate authorities. Identify case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within Grievances and Appeals and referring to appropriate IEHP Team Members. Assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for IEHP members. Notify Grievance & Appeals management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified IEHP members. Work with Team Members to support the protocols and goals of the department and the vision of the organization. Ensure clinical oversight of assigned Grievance and Appeals team cases specific to accurate and appropriate categorization of Quality-of-Care grievance cases and timely identification of Member Harm. Provide direction/guidance to G&A LVNs as it pertains to Quality-of-Care categorization and mis-categorization, Member Harm, Immediate Needs, PQI/Critical incident identification and reporting. Ensure all necessary follow up is tasked for completion by designated MedHOK business partners, to include timely reporting of critical incidents, potential quality incidents and provider preventable conditions Generate written correspondence to Providers, members, and regulatory entities utilizing approved templates with use of appropriate grammar and punctuation. Prepare files for Grievance and Appeals Committee reviews. Maintain all Grievance & Appeals documentation according to external agency requirements. Audit daily reports to assure all Quality-of-Care grievance and appeal cases are captured and opened within regulatory timeframes, to include the identification of Member Harm. Prepare and finalize administrative appeal cases to include final review decision, appropriate application of review criteria and final resolution to member and requesting Provider. Perform any other duties as required to ensure Health Plan operations and department business needs are successful. Qualifications: Education & Requirements Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting required Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting required Associate's Degree in Nursing from an accredited institution required Bachelor's Degree in Nursing from an accredited institution preferred Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required Key Qualifications Knowledge of: Outside agencies and resources such as CCS, CMS, DMHC, or DHCS Patient rights and ethical decision-making frameworks Medical necessity and level of care, chronic disease and complex clinical cases Diagnostic and procedural understanding in a clinical setting Regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA Member and Provider legal rights to access the grievance and appeals resolution process, within the respective Provider Organization, DHCS, DMHC, and CMS, and/or IEHP Microcomputer applications: spreadsheet, database, and word processing; Excellent interpersonal and communication skills Time management and priority setting skills Proven ability to: Demonstrate a commitment to incorporate LEAN principles into daily work Work effectively with various internal departments and external Providers and entities Assess complex Grievance & Appeal cases and recommend appropriate action Analyze documentation of incoming cases to determine appropriateness of care and applicable next steps Effectively escalate issues as identified, following established protocols Maintain a positive attitude and work in a team setting Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus Start your journey towards a thriving future with IEHP and apply TODAY ! Work Model Location: Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range: USD $91,249.60 - USD $120,910.40 /Yr. 
