Nursing Jobs in West Hills, 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 (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 NursingEducation Preferred Bachelor's Degree in NursingExperience 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 LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional 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) 
$132,787.20 - $154,294.40 / year
Purpose Statement/Position Summary: The Advanced Practice Provider (APP) in the Anesthesiology Department delivers comprehensive, patient-centered care in collaboration with a multidisciplinary healthcare team. This role prioritizes direct patient care while actively contributing to divisional quality improvement initiatives and the enhancement of clinical outcomes. Additionally, the APP supports orientation efforts and provides education to patients, families, and team members to promote understanding and engagement in care. APP patient coverage may require, regularly scheduled days and occasional weekends. Minimum Qualifications/Work Experience: Required: Enhanced knowledge of pediatric patient care principles, and ability to manage specialty patient care and emergencies by prioritizing patient care acuity and tasks, collaborating with entire care team critically, comprehensively both verbally and in writing. Preferred: Pediatric clinical experience. Pediatric ICU experience strongly preferred. Experience with CERNER/KIDS charting preferred. Education/Licensure/Certification: Required: Master's Degree from an accredited college or universityPA - Physician Assistant State License or NP - Nurse Practitioner LicenseDEA - Drug Enforcement AdministrationAmerican Health Association BLS - Basic Life Support & PALS - Pediatric Advanced Life SupportNRP - Neonatal Resuscitation Provider (NICCU only) (NP) Required: Pediatric Nurse-Practitioner Acute-Care OR DUALPediatric Nurse-Practitioner Primary-careFamily Nurse-Practitioner (Post-Master’s Pediatric Preferred)Neonatal Nurse-Practitioner (NICCU Only) 
$150,000 - $160,000 / year
SUMMARY Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the residents. Maintains for each level of nursing personnel the nursing services philosophy and objectives, standards and practice, policies and procedures, and job descriptions. Provides quality care that is consistent with company and regulatory standards. May be designated to assume responsibilities of daily operations of the facility in the Administrator’s absence. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. ● Provides nursing staff is providing quality and appropriate resident / patient care that meets or exceeds company and regulatory standards. ● Assists in the preparation of annual budget for facility. Monitors monthly performance of nursing services in relation to budget and intervenes as needed. ● Schedules and performs resident / patient rounds to monitor and evaluate the quality and appropriateness of nursing care. ● Maintains administrative authority, responsibility and accountability for the proper charting and documentation of care and of medications and treatments. ● Recruits, hires, provide orientation/training, and retain a sufficient number of qualified staff to carry out nursing programs and services. Oversees employee performance meets or exceeds expectations and periodic performance appraisals are conducted on a timely basis. ● Disciplines staff in accordance with facility protocols and regulations. ● Develops and implements the written staffing plan and nursing schedule that reflects the needs of the resident and resident population. ● Confirms all required records are maintained and submitted, as appropriate, in an accurate and timely manner. ● Evaluates current and potential residents and patients to confirm facility can provide appropriate level of care. ● Evaluates market studies and develops clinical programs to meet the needs of the community. ● Maintains regular and ongoing communication with facility Medical Director ensuring programs and care services meet the needs of patients / residents. ● Promotes residents’/patients’ rights. ● Promotes environment of care standards and regulations applicable to the nursing practice. ● Reinforces infection control protocols and regulations. ● Applies process improvement methods and techniques; identifies processes for improvement in daily work. ● Completes required forms and documents in accordance with company policy and state and/or federal regulations. ● Manages all aspects of state or federal government survey processes. ● May occasionally be required to perform patient care duties. ENTRY QUALIFICATIONS ● Graduate of an accredited school of Nursing, Bachelors of Science in Nursing preferred ● Valid State licensure as an RN ● Maintains current CPR certification ● Additional certification in nursing specialty desired ● Two to three (2-3) years of management or supervisory experience in long-term care, acute care, restorative or geriatric nursing preferred ● Other certifications as required by State ● Proficient in the use of personal computer SUPERVISORY RESPONSIBILITIES Supervises nursing staff and others for whom they are administratively or professionally responsible. LANGUAGE SKILLS Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures or government regulations. Ability to write reports, business correspondence, nursing/resident/patient progress notes and nursing procedures. Ability to effectively present information and respond to questions from department heads, customers (residents/patients, responsible parties, family members, physicians, etc.) and the general public. Computer skills preferred. INTERPERSONAL SKILLS Demonstrates active listening techniques; gains support through effective relationships; treats others with dignity and respect; seeks feedback; sets clear standards for performance; evaluates job performance and provides feedback; establishes systems to measure effectiveness; efficiency and service; creates and maintains reporting mechanisms. MATHEMATICAL SKILLS Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions and decimals. Ability to compute, rate, ratio and percent, ability to draw and interpret bar graphs. REASONING ABILITY Ability to solve practical problems and deal with variety of concrete variables. Ability to interpret an extensive variety of instructions furnished in oral, written, diagram or schedule form. LEADERSHIP SKILLS Demonstrates willingness to try new tasks, generates new ideas for change, evaluates and recognizes priorities, challenges others to learn, keeps current and integrates new information, communicates and models organization values and fosters high performance. PHYSICAL DEMANDS AND ENVIRONMENT May be required to respond to critical issues on a 24/7 basis. Employee is frequently required to stand, walk, use hands or fingers, reach with hands and arms, feel, talk and hear. Employee will occasionally assist to lift and / or transfer patients weighing between 100 to 250 pounds. Employee is occasionally exposed to blood or other body fluids, fumes or airborne particles and toxic or caustic chemicals. In compliance with applicable law, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions for the position. OTHER REQUIREMENTS Participates in (or conducts) company-sponsored training to safeguard against improper use and disclosure of resident’s protected health information. Monitors and oversees facility’s efforts to comply with company policies, procedures and state and federal law. By his / her signature below, employee agrees to adhere to and oversee communication of privacy guidelines relative to the confidentiality of residents' protected health information. JOB DESCRIPTION REVIEW I understand this job description, its requirements and that I am expected to complete all duties as assigned. I understand the job duties may be altered from time to time. WAGE RATE: FROM $150000.00 to $160000.00 PER YEAR DEPENDING ON EXPERIENCE 
