L.A. Care Health Plan
Utilization Management Nurse Specialist RN II
L.A. Care Health Plan, Los Angeles, California, United States, 90079
Job Category: ClinicalLocation: Los Angeles, CA, US, 90017Position Type: Full TimeRequisition ID: 11229Salary 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 in five health plans, ensuring 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.Position Overview
The Utilization Management Nurse Specialist RN II will facilitate, coordinate, and approve medically necessary referrals that meet established criteria. Responsibilities include:Assuring timely and accurate determination and notification of referrals and reconsiderations.Generating approval, modification, and denial communications.Actively monitoring for admissions in any inpatient setting.Performing telephonic and/or on-site admission and concurrent review.Collaborating with onsite staff, physicians, providers, and members to develop and implement a successful discharge plan.Working with the UM Manager and Physician Advisor on case reviews.Monitoring and overseeing the collection and transfer of data (medical records) and referral requests.Acting as a department resource for medical service requests/referral management.Handling incoming calls from providers and resolving inquiries professionally.Duties
Promote and support team engagements, programs, and activities to create a positive workplace environment.Process and facilitate inbound requests from providers.Generate appropriate communication for all determinations within required timelines.Facilitate/review requests for higher level of care or skilled nursing/discharge planning needs.Identify and initiate referrals for appropriate members to various L.A. Care programs.Document all actions in the platform/system of record.Perform other duties as assigned.Education Required
Associate's Degree in NursingEducation Preferred
Bachelor's Degree in NursingExperience
Required:
At least 5 years of varied clinical experience in an acute hospital setting and 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:
Computer literacy with expertise in Outlook, Word, Excel, PowerPoint; strong verbal and written communication skills; excellent time management and priority-setting skills; and compliance with HIPAA requirements.Preferred:
Knowledge of NCQA requirements for Utilization Management or Care Management and knowledge of DHCS or CMS requirements for health plan compliance.Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California LicensePhysical Requirements
LightAdditional Information
May work 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 ReimbursementRetirement PlansMedical, Dental and VisionWellness ProgramNearest Major Market:
Los AngelesJob Segment:
Nursing, Registered Nurse, Medicare, Medicaid, Claims, Healthcare, Insurance
#J-18808-Ljbffr
$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 in five health plans, ensuring 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.Position Overview
The Utilization Management Nurse Specialist RN II will facilitate, coordinate, and approve medically necessary referrals that meet established criteria. Responsibilities include:Assuring timely and accurate determination and notification of referrals and reconsiderations.Generating approval, modification, and denial communications.Actively monitoring for admissions in any inpatient setting.Performing telephonic and/or on-site admission and concurrent review.Collaborating with onsite staff, physicians, providers, and members to develop and implement a successful discharge plan.Working with the UM Manager and Physician Advisor on case reviews.Monitoring and overseeing the collection and transfer of data (medical records) and referral requests.Acting as a department resource for medical service requests/referral management.Handling incoming calls from providers and resolving inquiries professionally.Duties
Promote and support team engagements, programs, and activities to create a positive workplace environment.Process and facilitate inbound requests from providers.Generate appropriate communication for all determinations within required timelines.Facilitate/review requests for higher level of care or skilled nursing/discharge planning needs.Identify and initiate referrals for appropriate members to various L.A. Care programs.Document all actions in the platform/system of record.Perform other duties as assigned.Education Required
Associate's Degree in NursingEducation Preferred
Bachelor's Degree in NursingExperience
Required:
At least 5 years of varied clinical experience in an acute hospital setting and 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:
Computer literacy with expertise in Outlook, Word, Excel, PowerPoint; strong verbal and written communication skills; excellent time management and priority-setting skills; and compliance with HIPAA requirements.Preferred:
Knowledge of NCQA requirements for Utilization Management or Care Management and knowledge of DHCS or CMS requirements for health plan compliance.Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California LicensePhysical Requirements
LightAdditional Information
May work 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 ReimbursementRetirement PlansMedical, Dental and VisionWellness ProgramNearest Major Market:
Los AngelesJob Segment:
Nursing, Registered Nurse, Medicare, Medicaid, Claims, Healthcare, Insurance
#J-18808-Ljbffr