Nursing Jobs in West Covina, 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) 
$160,430.40 - $225,992 / year
Title: CTS Nurse Practitioner Location: Long Beach Department: Cardiology Pro Fees Status: Full-time Shift: Day Pay Range*: $160,430.40 - $225,992.00/annually MemorialCare is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups – consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to MemorialCare's recognition as a market leader and innovator in value-based and other care models. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork. Position Summary The Nurse Practitioner (NPII) practices as a member of the interdisciplinary healthcare team using standardized procedures to independently examine, diagnose and treat patients in collaboration with supervising physician(s). The incumbent supports management in achieving a high-quality program for specific patient populations, for both clinical outcomes and customer service in an efficient manner. The NP II is knowledgeable of the latest clinical trends, best practices, regulatory requirements and reimbursement patterns for patients in the specialty program. Essential Functions and Responsibilities of the Job Expert Clinical Practice and Collaboration A. Independently examines, diagnoses, orders diagnostic studies and treatment for patients using approved standardized procedures. Evaluates the effectiveness of interventions and changes treatment as indicated. B. Provides direct patient/indirect care. 1. Coordinates, prioritizes and organizes individual patient care in collaboration with supervising physician(s 2. Collaborates with members of the healthcare team to create a patient plan of care. 3. Provides individualized patient and family education and documents in the patient teaching plan. 4. Communicates with supervising physician and physician consultants treating the patient. 5. Anticipates discharge on admission and plans accordingly. 6. Ensures accurate patient problem list and medication reconciliation on admission and discharge. 7. Utilizes age specific competencies for culturally diverse patients. 8. Ensure accuracy of acuity with appropriate diagnostic documentation. 9. Ensures a seamless transition through the hospital continuum of care. May follow in an outpatient clinic or physician’s office. 10. May be the NP -nurse navigator for the patients through the healthcare continuum. 11. May practice in a clinic, inpatient setting and/or outpatient setting. 12. May oversee support groups for specific patient diagnosis or population. Specialty Care Development A. Identifies ideas and insights into clinical improvements for specialty patient population. B. Ensure that queries generated by medical records regarding the accuracy of documentation have an appropriate response. C. Monitor and manage the patient progression through hospitalization. D. May oversee the accurate collection and entry of data specific to patient population. May prepare or oversee the preparation of reports regarding specialty care. E. Reviews clinical outcomes, progression of care, and financial indicators with appropriate Medical Directors and other specialty physicians. F. May provide education for members of the interprofessional team regarding special needs in the care of specialty patient population. G. Acts as a consultant to other CareLines, service lines, BPTs on specialty specific patient care needs. Quality Improvement and Research A. Recommends, supports, participates or leads quality improvement initiatives regarding specialty care. B. Should participate as an investigator, co-investigator in research studies specific to patient population. C. Participates a requested in peer review activities. Additional responsibilities: 1. Complies with all policies and procedures. 2. Participates in the orientation and development of students and/or new staff as assigned. 3. Maintains standardized procedures and privileging/credentialing requirements according to medical staff AHP rules and regulations. *Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high-quality health insurance plan options, so you can select the best choice for your family. And there’s more... Check out our MemorialCare Benefits for more information about our Benefits and Rewards. 
