L.A. Care Health Plan
Utilization Management Nurse Specialist RN II
L.A. Care Health Plan, Los Angeles, California, United States, 90079
Job Category: Clinical
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID:
11229
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 in five health plans.
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.
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 based on the referral determination status.
Generating approval, modification, and denial communications, including member and provider notification of referral determination.
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 for pre-service, concurrent, post-service, and retrospective claims medical review.
Monitoring and overseeing the collection and transfer of data (medical records) and referral requests by Providers.
Acting as a department resource for medical service requests/referral management and processes.
Receiving incoming calls from providers, professionally handling complex calls, and researching to identify timely and accurate resolution steps.
Performing other duties as assigned.
Education RequiredAssociate's Degree in Nursing
Education PreferredBachelor's Degree in Nursing
ExperienceRequired:At least 5 years of varied clinical experience in an acute hospital setting. At least 2 years 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.
SkillsRequired: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.
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 RequiredRegistered Nurse (RN) - Active, current and unrestricted California License
Physical RequirementsLight
Additional InformationMay 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 Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
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Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID:
11229
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 in five health plans.
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.
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 based on the referral determination status.
Generating approval, modification, and denial communications, including member and provider notification of referral determination.
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 for pre-service, concurrent, post-service, and retrospective claims medical review.
Monitoring and overseeing the collection and transfer of data (medical records) and referral requests by Providers.
Acting as a department resource for medical service requests/referral management and processes.
Receiving incoming calls from providers, professionally handling complex calls, and researching to identify timely and accurate resolution steps.
Performing other duties as assigned.
Education RequiredAssociate's Degree in Nursing
Education PreferredBachelor's Degree in Nursing
ExperienceRequired:At least 5 years of varied clinical experience in an acute hospital setting. At least 2 years 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.
SkillsRequired: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.
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 RequiredRegistered Nurse (RN) - Active, current and unrestricted California License
Physical RequirementsLight
Additional InformationMay 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 Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
#J-18808-Ljbffr