RN Outpatient Utilization Review Outpatient
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II (Outpatient)

L.A. Care Health Plan Los Angeles, 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)
RN Manager/Supervisor Utilization Review Telehealth
L.A. Care Health Plan

Supervisor, Utilization Management RN

L.A. Care Health Plan Los Angeles, 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 Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. 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)
RN Utilization Review Telehealth
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

L.A. Care Health Plan Los Angeles, 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)
RN Manager/Supervisor Telehealth
L.A. Care Health Plan

Supervisor, Appeals and Grievances Clinical Operations RN

L.A. Care Health Plan Los Angeles, 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 Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the day-to-day clinical operations of the A&G department, and monitoring the A&G RN staff responsibilities and activities. This includes, but is not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolutions within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Appeals & Grievances and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible for assisting with and development and maintenance of a successful and cohesive unit, with a high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the A&G department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A Care's culturally diverse membership. The position supports the A&G Clinical Manager. This role also assists the A&G Leadership in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of A&G staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors staff’s performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the A&G team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees A&G clinical activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Duties Continued Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Fosters a culture that encourages employee contribution to ensure the department maintains an environment in which quality flourishes. Serves as a member/resource/liaison to the A&G Operations Team. Recommends resources to improve performance standards in terms of Appeals & Grievances. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 8 years of RN acute/clinical care experience. At least 2 years in a lead/supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Preferred: Previous experience in Medicare/ Medicaid in a managed care/ health plan environment.Skills Required: Knowledge of state, federal and regulatory requirements in Appeals/Care/Case/Utilization Management/Quality. Strong verbal and written communication skills. Computer literacy with proficiency in Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, 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)
RN Telehealth
L.A. Care Health Plan

Managed Long Term Services and Supports Nurse Specialist RN II

L.A. Care Health Plan Los Angeles, 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 Managed Long-Term Services and Supports (MLTSS) Nurse Specialist RN II applies advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for L.A. Care members. Utilizes assessments, member-centered care planning, direct provider coordination/collaboration and psychosocial wraparound services to promote effective utilization of available Health Plan benefits including, but not limited to Community Based Adult Services (CBAS), Skilled Nursing Facility (SNF) services, Intermediate Care Facility for Developmentally Disabled (ICF/DD) services, CalAIM Community Supports, Palliative and Hospice Care. Scope of work includes care coordination functions and must adhere to regulatory mandates that apply to Utilization Management (UM) and Care Management (CM). This position is responsible for assessing, planning, coordinating, and monitoring care needs to ensure members receive high-quality, cost-effective care that promotes independence and quality of life. The MLTSS Nurse Specialist RN II conducts comprehensive health assessments and is a member of an interdisciplinary team that is key in identifying the physical, psychological and social needs of the member. The MLTSS Nurse Specialist RN II collaborates with Skilled Nursing Facilities (SNF), Intermediate Care Facility - Developmentally Disabled (ICF-DD), Community Based Adult Services (CBAS) Centers, Residential Care Facilities for the Elderly (RCFE), Preferred Provider Groups (PPG), CalAIM providers (i.e. Community Supports Vendors), Palliative and Hospice Care Providers and cross functional units to facilitate coordination of services. This position may require provider onsite visits as needed. Duties Responsible for performing assessments and clinical review of medical records to determine appropriate care including physical health, behavioral health, and social determinants of health needs for members referred to; MLTSS administered programs. Responsible for UM authorization functions for services requiring prior authorizations in a timely manner with adherence to regulatory requirements. Identify and address gaps in care or overutilization, including overlapping services. Engages with members by conducting telephonic nursing follow up and care coordination when necessary, including transitions of care for Long Term Care (LTC) and ICF/DD populations. Provides direction to non-clinicians who assist members with accessing services and arranges for all services required while coordinating with the health care team to eliminate duplication of services. Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for MLTSS and other programs. Establishes relationships with referral sources and community resources, such as external providers and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Performs oversight and monitoring of provider performance for adherence to regulatory standards and contractual agreements. Participate in provider audits and quality improvement initiatives. Partners with Provider Network Management (PNM) and participates in Joint Operations Meetings (JOM). Duties Continued Facilitates care coordination with and provides education on available services to internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach minimizes member confusion, and ensures the best care is delivered in the most appropriate setting. Documents accurately and comprehensively based on the standards of practice and current organization policies. Performs other CM and UM functions as assigned and as needed /required by L.A. Care, to maintain regulatory requirements and company objectives. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 3 years of clinical nursing experience in direct patient care, such as ambulatory care, home care, palliative care, hospice care OR experience in Utilization Review or Care Management will be considered in lieu of direct patient care that may include at least 2 years of relevant Licensed Vocational Nurse (LVN) experience in a UM or CM capacity substituted for 1 year of RN experience. Clinical experience working with individuals with chronic illnesses, comorbidities, and/or disabilities in a UM/CM environment. Preferred: Experience in utilization review, skilled nursing, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agencies. Skills Required: Excellent verbal and written communication skills; with effective charting practices. Excellent organizational, time-management and priority-setting skills. Strong clinical skills with a knowledge of care needs for elderly, disabled, and/or frail populations and has applied knowledge of End-of-Life care. Customer Service Skills: Provision of excellent customer service required due to frequent communication with providers, members and interdisciplinary team. Technical Skills: Must be computer literate and proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint, Teams). Ability to effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System. Ability to maintain strict member confidentiality and complies with all HIPAA requirements. Preferred: Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)Required Training Physical Requirements LightAdditional Information Required: Travel to offsite locations for work. 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)
RN Telehealth Full-time
L.A. Care Health Plan

Delegation Oversight Clinical Auditor RN II

L.A. Care Health Plan Los Angeles, 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 Delegation Oversight Clinical Auditor RN II is responsible for ensuring that delegates contracted to perform Utilization Management (UM) functions on behalf of L.A. Care (LAC) is in compliance with all UM regulatory requirements and new legislation through the maintenance of required policies/procedures/workflows/ processes/audit tools necessary to meet the requirements. This position utilizes a rapid team approach for needed improvements identified through external audits of delegated entities. This position assist in maintaining continuous quality improvement in the Delegation Oversight Clinical Audit unit ensuring that departmental/divisional and organizational goals are accomplished through overseeing and facilitating compliance of the Plan Partners, Participating Provider Groups (PPG), Specialty Health Plans (SHP), and contracted provider network as managed by the Delegation Oversight Department. This position is responsible, as part of the oversight team, for ensuring compliance of the Plan Partners and/or Participating Physician Groups (PPG) to regulatory, contractual and L.A. Care requirements. This position is responsible for performing annual and focused audits. This position also acts as a liaison between the Plan Partners and PPGs and L.A. Care Health Plan regarding UM issues. The position assists in improving access and utilization performance of Plan Partners and PPGs by being a resource for best practices and providing continuous feedback. Additionally, the oversight responsibility of this position includes reporting to management and providing consultation/instructional/coaching recommendations to improve overall compliance of Plan Partners and PPGs with all regulations and standards. Duties Continually ensures delegate compliance with UM Policies/Procedures, Letter Templates, Workflows, Processes, and Audit Tools in compliance with all regulatory requirements/new legislation. Works collaboratively with Regulatory Affairs & Compliance. Stay abreast of new UM legislation, regulations, or other changes impacting UM in order to put processes in place for compliance. Prepares the Delegation Oversight Clinical Audit team for internal audits and for conducting PP/PPG audits, developing mechanisms for tracking/ trending of progress for --UM/PPG (internal) and PP (external) for compliance with UM standards, and identities system/individual areas for improvement through these processes. Prepares the Delegation Oversight Department for review by external regulatory bodies. Ensures that the Delegation Oversight Department is continually prepared for external review with staff daily work conducted in a manner that meets regulatory requirements. Ensures that the Delegation Oversight Clinical Audit unit functions as a team in preparing needed documents for an external review. Completes annual, focused and periodic audit activities timely and thoroughly including identification of deficiencies, response to mitigation, review and response to CAPs. Identifies repeat deficiencies. Assures audit documentation is clear, complete and accurate. Completes periodic monitoring of PP or PPG performance in critical deficiency areas. Completes follow-up audits and related reports and recommendations. Identifies options to assist PP or PPGs with continued or significant deficiencies. Updates audit tools to meet regulatory, contractual and L.A. Care requirements. Develops and conducts ongoing monitoring activities including but not limited to file reviews and letters and supplemental reports. Present summary results to L.A. Care's UM Committee. Communicates with assigned PP and PPGs on an ongoing basis. Develop mechanism to track and trend progress of PP and PPG's compliance to UM standards and identify system wide issues. Maintains confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assists co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions. Actively identifies and makes recommendations to supervisor ideas to improve the quality effectiveness and efficiency of departmental and health services functions. Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner. Duties Continued Provides training, education and consultation as necessary to PP and PPGs. Collaborates with other Clinical Auditors on identifying topics and developing agendas for the JOM's and PP visits/communication. Develops and implements procedures to assure compliance with care coordination and documentation of linked and carved out services. Conducts Interrater Reliability Testing (referral management and oversight) for new staff/physicians and annually or as needed for existing staff/physicians. Works with other departments as necessary to facilitate teamwork for creating and/or improving interdepartmental processes to meet regulatory requirements. Clinical Auditor (Performance Monitoring): In addition to the responsibilities above, the Clinical Auditor (Performance Monitoring) position ensures compliance of the delegates (Participating Physician Groups, Plan Partners and Vendors) with regulatory, contractual and L.A. Care business requirements. This position is responsible for delegation oversight continuous monitoring activities and monitoring corrective action plans from the annual and focused audits. The position also acts as a liaison between the Plan Partners, PPGs and Vendors regarding Utilization Management (UM) issues; assists in improving access and utilization performance of PPGs by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility of this position includes attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards. Clinical Auditor (Behavioral Health): In addition to the duties above, the Clinical Auditor (Behavioral Health) designs an audit program specific to ensuring delegates are meeting behavioral health regulatory requirements. This ensures Specialty Health Plans and Plan Partners are in compliance with regulatory, contractual, and L.A. Care business requirements. This position is responsible for developing and maintaining annual audit tools, policy requirements specific to delegates, and a monitoring program to continually receive and aggregate Behavioral Health specific performance requirements. The position acts as a liaison between Specialty Health Plans and Plan Partners regarding Behavioral Health issues, assists in improving access and Behavioral Health performance by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility includes liasing with internal Behavioral Health units, the Medical Director of Behavioral Health, attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards. Performs other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 7 years in a clinical setting with at least 3 years in a managed care setting in Utilization Management/Case Management. Skills Required: Knowledge of issues pertaining to Medi-Cal and other HMO & IPA contracts, & payers. Ability to manage and organize large volumes of data. Knowledge of accreditation entities and their requirements. Excellent verbal and written communication skills and excellent interpersonal skills. Good working knowledge of regulatory requirements/standards. Ability to work independently. Ability to solve complex issues and identify creative solutions. Computer ease & literacy with Word, Excel, PowerPoint Skills. 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)
RN Telehealth
L.A. Care Health Plan

Clinical Policy Clinical Coder RN II

L.A. Care Health Plan Los Angeles, 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 Clinical Policy Clinical Coder RN II is responsible for analyzing, interpreting, and operationalizing medical and utilization management policies to ensure accurate coding, appropriate authorization requirements, compliant claims processing, and effective utilization oversight. This position serves as a key clinical and coding resource, translating medical policy requirements into diagnosis, procedure, and service code logic, including determining which codes require prior authorization. Conducts in-depth research and analysis of legislation and regulatory requirements, clinical outcomes, utilization, claims, and financial data to identify utilization trends, fiscal risk, and opportunities for policy enhancement and cost containment. This position works cross-functionally with internal teams to ensure policies are codified, consistently applied, and monitored through reporting and data analysis. This position collaborates closely with internal stakeholders and external entities to support standardized benefit administration, effective program implementation, and organizational compliance with state, federal, and accreditation requirements. Duties Translate approved clinical policies and utilization management criteria into clear, codified claims rules and system logic to support accurate claims adjudication. Develop, revise, and recommend clinical policies and internal utilization management criteria when standard clinical guidelines are insufficient to support appropriate decision-making based on codified claim rules. Assess the downstream claims impact of new or revised clinical policies prior to implementation and recommend configuration updates to mitigate operational or financial risk. Participate in validation of claims configuration changes to ensure policies are applied correctly and consistently across all lines of business. Monitor post-implementation claims activity to identify configuration issues, unintended denials, or payment discrepancies related to clinical policy application. Support remediation of claims configuration defects by identifying root causes and coordinating corrective actions with internal teams. Participate in and lead specialty and cross-functional workgroups and committees focused on healthcare services clinical policies, utilization management processes, strategic initiatives, policy governance, operational alignment, and continuous improvement efforts. Ensure timely dissemination of accurate and consistent policies and procedures across departments. Promote collaboration, engagement, and a positive work environment while supporting departmental initiatives and team-based activities. Manage assigned projects from concept through implementation, ensuring timelines, quality standards, and deliverables are met. Analyze and interpret medical and utilization management policies to identify applicable diagnosis, procedure, and service codes and determine authorization, pre-payment, or post-payment review requirements. Define and maintain code lists that require prior authorization or other utilization management controls based on clinical evidence, regulatory guidance, utilization trends, and financial risk.Duties Continued Collaborate with internal teams to ensure authorization requirements and coding logic are accurately configured in authorization and claims systems based on authorization matrix requirements. Support accurate claims processing by validating codified authorization and policy requirements are correctly applied and aligned with approved medical policies. Provide clinical and coding recommendations to support the development, revision, and implementation of new or updated medical and utilization management policies. Investigate and resolve coding and authorization related issues, including claim denials, coding edits, authorization discrepancies, and policy interpretation questions. Review and assess claims edits, authorization matrixes, and coding rules to identify root causes of errors or inconsistencies and recommend corrective actions. Ensure coding, authorization requirements, and claims-related guidance align with medical necessity criteria, benefit structures, and applicable state, federal, and regulatory requirements. Develop, review, and maintain reporting related to authorization required codes, approval and denial rates, utilization patterns, claims payment outcomes, and policy effectiveness. Prepare reports, summaries, and presentations and communicate findings, recommendations, and action plans to internal and external stakeholders. Analyze claims, authorization, and utilization data to identify trends, measure policy impact, and recommend opportunities for policy refinement, cost containment, or reduction of administrative burden. Monitor post-implementation performance of authorization-required codes and recommend additions, removals, or modifications to authorization requirements based on regulatory thresholds and utilization outcomes. Perform other duties as assigned.Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 8 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. Experience with medical coding systems. Preferred: At least 1 year of experience in editing and writing clinical health services policies within a managed care health plan. Skills Required: Proficient with clinical policy through skills in literature searching and clinical research analysis based on the best available evidence. Working knowledge of clinical policies. Working knowledge of CPT/HCPC codes and claims. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong analytical, problem solving, and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Ability to identify discrepancies, assess risk, and recommend actionable solutions. Knowledge of medical coding systems, including ICD-10-CM, CPT, and HCPCS, and their application in authorization and claims environments. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Proficient in claims configuration, including claims adjudication workflows, configuration of claims edits and rules, and the translation of clinical and utilization management policies into system-based claims logic to support accurate, compliant payment outcomes. Understanding of the managed care industry and market conditions.Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Professional Coder (CPC)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)
RN Telehealth
L.A. Care Health Plan

Clinical Policy Nurse RN II

L.A. Care Health Plan Los Angeles, 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 Clinical Policy Nurse RN II is responsible for analytical research, trending, and assessment based on legislation, regulatory and accreditation requirements that impact claims, Utilization Management (UM) department and healthcare services policies. Reviews and analyzes clinical financial data to assess the effectiveness of existing and proposed policies to identify opportunities for improvement, cost containment, and quality enhancement. This position plays a key role in translating regulatory impacts into operational strategies and works collaboratively with internal and external stakeholders to ensure clinical policies support safe, effective, and compliant care delivery. Assists in development of policies and programs that improve health outcomes and target Fraud, Waste and Abuse (FWA). This position works cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The Clinical Policy Nurse II serves as a liaison to ensure the ongoing maintenance of clinical coding for the authorization matrix.Duties Assess federal, state, and local legislation, regulatory guidance, and health care policies to identify potential impacts on clinical practice, reimbursement and organizational operations that impact healthcare services policies. Review and interpret clinical, utilization, and financial data to identify trends, opportunities for policy improvement and cost-savings. Research, develop, and evaluate clinical and health policy designed to improve patient outcomes, detect and mitigate Fraud, Waste, and Abuse (FWA), and streamline organizational processes. Monitor the implementation of health programs, clinical initiatives, and community action plans to assess effectiveness, compliance, and impact on patient outcomes. Collaborate with internal stakeholders to evaluate utilization trends and anomalies and contribute to policy development aimed at improving efficiency and compliance identified during risk assessments. Prepare analytical reports, summaries, and analyses assessing policy performance, regulatory impact, and communicate insights and recommendations to stakeholders to drive evidence-based policy and impacted outcomes. Present findings, recommendations, and action plans to key stakeholders. Participate in work groups related to healthcare services clinical policies and procedures including efforts to improve department processes, as needed. 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 active participation in state regulatory audits such as Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and/or National Committee for Quality Assurance (NCQA) audits. At least 1 year of experience in clinical health services policies with a managed care plan. Skills Required: Demonstrated strong reporting skills by preparing clear, concise reports and presentations that communicate findings and performance. Working knowledge of clinical policies. Strong analytical and critical thinking skills with the ability to interpret regulatory requirements and legislation. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong problem solving and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Understanding of the managed care industry and market conditions. 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)
RN Utilization Review
L.A. Care Health Plan

Utilization Management Admissions Liaison RN II

L.A. Care Health Plan Los Angeles, 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) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team 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. 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 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)American Case Management Association (ACM)Required Training Physical Requirements LightAdditional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. 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)
RN Utilization Review Telehealth
L.A. Care Health Plan

Utilization Management Admissions Liaison RN II (Nights)

L.A. Care Health Plan Los Angeles, 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) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team 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. 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 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)American Case Management Association (ACM)Required Training Physical Requirements LightAdditional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. 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)
RN Telehealth Full-time
L.A. Care Health Plan

Clinical Policy Clinical Coder RN II

L.A. Care Health Plan Los Angeles, 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 Clinical Policy Clinical Coder RN II is responsible for analyzing, interpreting, and operationalizing medical and utilization management policies to ensure accurate coding, appropriate authorization requirements, compliant claims processing, and effective utilization oversight. This position serves as a key clinical and coding resource, translating medical policy requirements into diagnosis, procedure, and service code logic, including determining which codes require prior authorization. Conducts in-depth research and analysis of legislation and regulatory requirements, clinical outcomes, utilization, claims, and financial data to identify utilization trends, fiscal risk, and opportunities for policy enhancement and cost containment. This position works cross-functionally with internal teams to ensure policies are codified, consistently applied, and monitored through reporting and data analysis. This position collaborates closely with internal stakeholders and external entities to support standardized benefit administration, effective program implementation, and organizational compliance with state, federal, and accreditation requirements. Duties Translate approved clinical policies and utilization management criteria into clear, codified claims rules and system logic to support accurate claims adjudication. Develop, revise, and recommend clinical policies and internal utilization management criteria when standard clinical guidelines are insufficient to support appropriate decision-making based on codified claim rules. Assess the downstream claims impact of new or revised clinical policies prior to implementation and recommend configuration updates to mitigate operational or financial risk. Participate in validation of claims configuration changes to ensure policies are applied correctly and consistently across all lines of business. Monitor post-implementation claims activity to identify configuration issues, unintended denials, or payment discrepancies related to clinical policy application. Support remediation of claims configuration defects by identifying root causes and coordinating corrective actions with internal teams. Participate in and lead specialty and cross-functional workgroups and committees focused on healthcare services clinical policies, utilization management processes, strategic initiatives, policy governance, operational alignment, and continuous improvement efforts. Ensure timely dissemination of accurate and consistent policies and procedures across departments. Promote collaboration, engagement, and a positive work environment while supporting departmental initiatives and team-based activities. Manage assigned projects from concept through implementation, ensuring timelines, quality standards, and deliverables are met. Analyze and interpret medical and utilization management policies to identify applicable diagnosis, procedure, and service codes and determine authorization, pre-payment, or post-payment review requirements. Define and maintain code lists that require prior authorization or other utilization management controls based on clinical evidence, regulatory guidance, utilization trends, and financial risk. Duties Continued Collaborate with internal teams to ensure authorization requirements and coding logic are accurately configured in authorization and claims systems based on authorization matrix requirements. Support accurate claims processing by validating codified authorization and policy requirements are correctly applied and aligned with approved medical policies. Provide clinical and coding recommendations to support the development, revision, and implementation of new or updated medical and utilization management policies. Investigate and resolve coding and authorization related issues, including claim denials, coding edits, authorization discrepancies, and policy interpretation questions. Review and assess claims edits, authorization matrixes, and coding rules to identify root causes of errors or inconsistencies and recommend corrective actions. Ensure coding, authorization requirements, and claims-related guidance align with medical necessity criteria, benefit structures, and applicable state, federal, and regulatory requirements. Develop, review, and maintain reporting related to authorization required codes, approval and denial rates, utilization patterns, claims payment outcomes, and policy effectiveness. Prepare reports, summaries, and presentations and communicate findings, recommendations, and action plans to internal and external stakeholders. Analyze claims, authorization, and utilization data to identify trends, measure policy impact, and recommend opportunities for policy refinement, cost containment, or reduction of administrative burden. Monitor post-implementation performance of authorization-required codes and recommend additions, removals, or modifications to authorization requirements based on regulatory thresholds and utilization outcomes. Perform other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 8 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. Experience with medical coding systems. Preferred: At least 1 year of experience in editing and writing clinical health services policies within a managed care health plan. Skills Required: Proficient with clinical policy through skills in literature searching and clinical research analysis based on the best available evidence. Working knowledge of clinical policies. Working knowledge of CPT/HCPC codes and claims. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong analytical, problem solving, and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Ability to identify discrepancies, assess risk, and recommend actionable solutions. Knowledge of medical coding systems, including ICD-10-CM, CPT, and HCPCS, and their application in authorization and claims environments. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Proficient in claims configuration, including claims adjudication workflows, configuration of claims edits and rules, and the translation of clinical and utilization management policies into system-based claims logic to support accurate, compliant payment outcomes. Understanding of the managed care industry and market conditions. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Professional Coder (CPC) 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)
RN Telehealth Full-time
L.A. Care Health Plan

Clinical Policy Nurse RN II

L.A. Care Health Plan Los Angeles, 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 Clinical Policy Nurse RN II is responsible for analytical research, trending, and assessment based on legislation, regulatory and accreditation requirements that impact claims, Utilization Management (UM) department and healthcare services policies. Reviews and analyzes clinical financial data to assess the effectiveness of existing and proposed policies to identify opportunities for improvement, cost containment, and quality enhancement. This position plays a key role in translating regulatory impacts into operational strategies and works collaboratively with internal and external stakeholders to ensure clinical policies support safe, effective, and compliant care delivery. Assists in development of policies and programs that improve health outcomes and target Fraud, Waste and Abuse (FWA). This position works cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The Clinical Policy Nurse II serves as a liaison to ensure the ongoing maintenance of clinical coding for the authorization matrix. Duties Assess federal, state, and local legislation, regulatory guidance, and health care policies to identify potential impacts on clinical practice, reimbursement and organizational operations that impact healthcare services policies. Review and interpret clinical, utilization, and financial data to identify trends, opportunities for policy improvement and cost-savings. Research, develop, and evaluate clinical and health policy designed to improve patient outcomes, detect and mitigate Fraud, Waste, and Abuse (FWA), and streamline organizational processes. Monitor the implementation of health programs, clinical initiatives, and community action plans to assess effectiveness, compliance, and impact on patient outcomes. Collaborate with internal stakeholders to evaluate utilization trends and anomalies and contribute to policy development aimed at improving efficiency and compliance identified during risk assessments. Prepare analytical reports, summaries, and analyses assessing policy performance, regulatory impact, and communicate insights and recommendations to stakeholders to drive evidence-based policy and impacted outcomes. Present findings, recommendations, and action plans to key stakeholders. Participate in work groups related to healthcare services clinical policies and procedures including efforts to improve department processes, as needed. 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 active participation in state regulatory audits such as Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and/or National Committee for Quality Assurance (NCQA) audits. At least 1 year of experience in clinical health services policies with a managed care plan. Skills Required: Demonstrated strong reporting skills by preparing clear, concise reports and presentations that communicate findings and performance. Working knowledge of clinical policies. Strong analytical and critical thinking skills with the ability to interpret regulatory requirements and legislation. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong problem solving and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Understanding of the managed care industry and market conditions. 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)
RN Telehealth Full-time
L.A. Care Health Plan

Lead Customer Solution Center Appeals and Grievances RN

L.A. Care Health Plan Los Angeles, 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)
RN Utilization Review Telehealth Full-time
L.A. Care Health Plan

Utilization Management Claims Review Nurse RN II

L.A. Care Health Plan Los Angeles, 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 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)
RN Utilization Review Telehealth Full-time
L.A. Care Health Plan

Utilization Management Clinical Quality Nurse Reviewer RN II

L.A. Care Health Plan Los Angeles, 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 Clinical Quality Nurse Reviewer RN II, under the purview of the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position focuses on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and creates reports on audit findings, as well as makes recommendations, to submit to the department's Quality Assurance Team and UM Management. Duties Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines. Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions. Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation. Works with department leadership to assess for all opportunities related to quality improvements. Compiles and presents quality report cards that measure adherence to quality and regulatory compliance. Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts. Serves as a consultant to the organization's Compliance team on an ad hoc basis. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree Master's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation. Preferred: Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. Background in teaching and/or clinical education. Skills Required: Superior verbal and written communication skills. Advanced computer proficiency in both Microsoft Word and Excel. Strong analytical and team building skills. Ability to work independently and be self-directed. Ability to work effectively with diverse team members. Strong problem-solving skills. Ability to multitask and streamline day-to-day operations. Ability to translate regulatory requirements into auditable tools. Preferred: Proven ability to lead successful performance improvement projects. 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)
RN Telehealth Full-time
L.A. Care Health Plan

Appeals and Grievances Nurse Specialist RN II

L.A. Care Health Plan Los Angeles, 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 Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to members with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, Fee for services (FFS) Medi-Cal/Medicare, or commercial insurance. Duties Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department. Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements. Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identification of Expedited Cases and resolution within 72 hours. Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation. Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE). Process the case thru to effectuation and final case documentation in the A&G system of record. Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE). Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director. When necessary, outreaches to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps. In instances where necessary, sends written notifications to appropriate parties. All interactions including verbal outreach and written communication will be documented in the A&G system of record. Participates inter-rater reliability training and assessments. 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 RN. At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment. Skills Required: Excellent interpersonal and communication skills. Computer literacy and adaptability to computer learning. Time management and priority setting skills. Must be organized and a team player Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. Good working knowledge of regulatory requirements/standards. 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, 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)