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<p><b>Salary Range:&nbsp;</b>&nbsp;$102,183.00&nbsp;(Min.) -&nbsp;$132,838.00&nbsp;(Mid.) -&nbsp;$163,492.00&nbsp;(Max.)</p><p>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.<br><br>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.<br></p><h4>Job Summary</h4><p>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.</p><p>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.</p><p>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.&nbsp; The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.</p><h4>Duties</h4><p>Ensures adequate/appropriate distributions of workforce, assignments and time off requests. &nbsp;Participates in the hiring and termination process providing recommendations with appropriate supporting documentation.</p><p>Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. &nbsp;Identifies, communicates and coaches to improve staff performance. &nbsp;Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. &nbsp;Completes intermittent and annual staff evaluations.</p><p>Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary.</p><p>Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals.</p><p>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.</p><p>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.</p><p>Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. &nbsp;Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. &nbsp;<br><br>Serves as a leader and role model as well as technical and informational resource for staff and peers.</p><h4>Duties Continued</h4><p>Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes.</p><p>Services as member/resource/liaison to the Interdisciplinary Care Team. &nbsp;</p><p>Recommends resources to improve performance standards in terms of Utilization Management. &nbsp;Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate.</p><p>Participates on internal and external committees as delegated or assigned.</p><p>Serves as a consultant to other departments or organizations as needed.</p><p>Responsible for the daily workflow and leading the work of assigned staff.&nbsp; This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff.</p><p>Performs other duties as assigned.</p><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p><b>Required:</b><br>Minimum of 7 years of acute/clinical care experience.<br></p><p>Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. </p><p>Minimum of 3 years leading process, program, or staff or supervisory experience.</p><p>Equivalency:&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><h4>Skills</h4><p><b>Required:</b><br>Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management.</p><p>Strong verbal and written communication skills.</p><p>Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software.</p><p>Excellent organizational, time management, and interpersonal skills.</p><p>Must be detailed-oriented, energetic, and an enthusiastic team player.</p><p>Must be able to work independently.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Healthcare                                                    </p>

L.A. Care Health Plan

Supervisor, Utilization Management RN

<p>SUMMARY</p><p>The <strong>Administrator</strong> is responsible for the overall daily management and operation of the clinic. The Administrator reports directly to first line regional operational management which may be an Area Director, Regional Director, or Vice President of Operations, depending on the region/demographics.</p><p>ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties and tasks may be assigned.</p><p>GROWTH · Develop and implement processes for program growth in accordance with Company goals. · Plan/coordinate patient scheduling to assure timely acceptance of patients and effective staffing levels. · Implement clinical and operational processes to improve patient health and minimize hospitalizations and missed treatments. · Achieve financial targets to include budget, labor costs, supply costs and expenditures.</p><p>OUTCOMES · Review all incident reports; make recommendations and take action relative to incidents as appropriate; report at monthly QAPI meeting. · Promote quality management program through education and involvement of staff and patients in outcomes as well as overall responsibility to achieve corporate goals for quality. Leads QAPI meetings and quality improvement committees. · Coordinate the functions of all departments and develop standards and methods of measuring patient care services, including a chronological record of services provided to patients as required by the ESRD Network Coordinating Council and Medicare. · Work with staff to maintain chronological, thorough, and appropriate documentation in the patient record of all treatments, activities, and communication with the patient, physician and other healthcare professionals. · Achieve program's target goals for patient outcomes in accordance with quality patient care and Company goals.</p><p>OPERATIONAL&nbsp;READINESS</p><p>· Knowledge of and remain current with federal, state, local laws and regulations, including health care professionals practice act requirements. · Assure that the clinic is in compliance with all applicable federal, state, and local laws and regulations and receives continuing certification from all statutory and regulatory agencies. · Develop, implement and follow up necessary Corrective Action Plans for internal and external surveys. · May assume Charge Nurse's responsibilities as needed. · Responsible for duties listed in Registered Supervising Nurse job description and nursing services policy # C-AD-0110 or must designate Registered Nurse meeting these qualifications. · May fulfill responsibility of facility CEO as delegated by Governing Body. · Conduct and/or participate in both formal and informal meetings with the governing body, Regional Director, Medical Director and the staff. Assure that appropriate staff meetings, in-service education meetings, and team patient care planning meetings are held monthly. Assure that Quality Assessment &amp; Performance Improvement Program is current at all times. · Establish, maintain, and submit all required records and reports concerning staff, patients, and the operational affairs of the center. · Plan, coordinate, and approve effective and efficient staffing to meet patient needs and regulations. · Oversee the maintenance of equipment and supplies to meet current laws and regulations.</p><p>OPERATIONAL READINESS (cont.) · Continuously monitor to ensure that a safe and sanitary physical environment is maintained throughout the facility; that all equipment is maintained and functions properly; and that adequate and appropriate inventory levels of all supplies are available and used correctly. · Supervise the maintenance of equipment, building areas occupied by the center and other property belonging to the center. · Know and understand the water treatment and mechanisms of the equipment of the facility. · Assist, when necessary, with disinfection of equipment and supplies including bicarbonate delivery systems and dialysis machines.</p><p>PARTNERSHIPS · Monitor all contractual agreements; update as needed with corporate oversight. · Maintain collaborative working relationship with Medical Director and physicians. · Establish and maintain a positive relationship with area hospitals, agencies, vendors and the community. · Actively promote GUEST customer service standards; develop effective relationships at all levels of the organization. · Respond effectively to inquiries or complaints.</p><p>STAFF&nbsp;DEVELOPMENT/&nbsp;RETENTION · Ensure all staff meet required qualifications for position held and perform duties within limitations established by and in accordance with company policy/procedures, health care professionals practice acts, applicable state and federal laws and regulations. · Recruit, train, develop, and supervise all personnel. · Maintain effective personnel management and employee relations, including evaluating the performance of all personnel; approving and submitting all hours worked and counseling and disciplining employees. · Uphold management goals of corporation by leading staff in team concepts and promoting a team effort. · Effectively communicates expectations; accepts accountability and holds others accountable for performance.</p><p>ADMINISTRATOR</p><p>State Specific Regulations</p><p>Alabama</p><p>IF DESIGNATED CEO FOR THE CLINIC, MUST: </p><ul><li> Hold at least a baccalaureate degree and has at least one (1) year of experience in a dialysis unit OR</li><li> Meets the qualifications for a qualified physician director or qualified registered supervising nurse.</li></ul><p>Georgia </p><ul><li> Hold at least a baccalaureate degree and has at least one (1) year experience in an end stage renal disease facility OR</li><li> Meets the qualifications for a physician director or a nurse responsible for nursing services for an end stage renal disease facility OR</li><li> Has been acting for at least two (2) years as a facility administrator for an end stage renal disease facility which has been certified for the federal Medicare program.</li></ul><p>Maryland </p><p> IF NOT THE DESIGNATED CEO FOR THE CLINIC, MUST: </p><ul><li> Be 21 years old or older.</li><li> Possess a high school diploma or a high school equivalency diploma.</li><li> Have at least one (1) year of dialysis experience.</li><li> Have no criminal conviction or other criminal history that indicates behavior that is potentially harmful to patients, documented through either a criminal history records check or criminal background check completed within one (1) month before employment.</li></ul><p>New Jersey </p><ul><li> A baccalaureate degree from an accredited college or university and the equivalent of at least one (1) year experience in supervising renal dialysis services OR</li><li> Five (5) years full-time experience in the provision of renal dialysis services and documentation of supervisory experience for at least one (1) year.</li></ul><p>South Carolina </p><ul><li> Hold at least a baccalaureate degree or have a minimum of an associate degree in a health-related field with at least two (2) years experience in ESRD within the past five (5) years.</li></ul><p>Wyoming </p><p> PERSON IN CHARGE OF THE OPERATION OF THE FACILITY TWENTY-FOUR (24) HOURS PER DAY AND IS:</p><ul><li> A physician OR</li><li> A Registered Nurse who has at least six (6) months of experience working in a renal dialysis center OR</li><li> An individual with a bachelors degree and one (1) year experience in health service administration, preferably in a renal dialysis center.</li></ul><p>REGISTERED SUPERVISING NURSE</p><p>State Specific Regulations</p><p>Georgia </p><ul><li> RN with twelve (12) months of experience in clinical nursing, and an additional six (6) months of experience in nursing care of the patient with permanent kidney failure or undergoing kidney transplantation, including training in and experience with the dialysis process OR</li><li> RN with eighteen (18) months of experience in nursing care of the patient with on maintenance dialysis, or the nursing care of the patient with a kidney transplant, including training in and experience with the dialysis process.</li><li> Where the RN responsible for nursing services is also in charge of self-care dialysis training, at least three (3) months of the total required dialysis experience is in training patients in self-care.</li></ul><p>New Jersey </p><p>THIS POSITION IS CONSIDERED DIRECTOR OF NURSING SERVICES IN THE STATE OF NJ AND MUST:</p><ul><li> Have twelve (12) months full time experience in nursing supervision and/or nursing administration obtained in a hemodialysis setting within the last twenty-four (24) months.</li></ul><p>South Carolina</p><p> THIS POSITION IS CONSIDERED DIRECTOR OF NURSING SERVICES IN THE STATE OF SC AND MUST: </p><ul><li> Be a registered nurse with at least eighteen (18) months of experience in clinical nursing, with at least six (6) months experience in care of patients with ESRD.</li></ul><p>Texas </p><p>THIS POSITION ALSO MAY BE KNOWN AS THE DIRECTOR OF NURSING IN THE STATE OF TX AND MUST:</p><ul><li> Have at least eighteen (18) months experience as an RN, which includes at least twelve (12) months experience in dialysis within the last twenty-four (24) months; OR </li><li> Have at least eighteen (18) months experience as an RN, and holds a current certification from a nationally recognized board in nephrology nursing or hemodialysis.</li></ul><br>

U.S. Renal Care

Dialysis Facility Administrator-RN Required

<p><b>Salary Range:&nbsp;</b>&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>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.<br><br>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.<br></p><h4>Job Summary</h4><p>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.</p><h4>Duties</h4><p><br>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. &nbsp;Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%)</p><p>Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. &nbsp;Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%)</p><p>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%)</p><p>Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%)</p><p>Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: &nbsp;Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%)</p><p><br>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%)</p><p>Performs other duties as assigned. (10%)</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p><b>Required:</b><br>Minimum of 7 years of clinical experience in an acute hospital setting.&nbsp;</p><p>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.</p><p><b>Preferred:</b><br>Consistent Critical Care experience (Emergency Department, Intensive Care, Labor &amp; Delivery) background highly desirable.</p><p>Experience in bed placement decision-making highly desirable.</p><h4>Skills</h4><p><b>Required:</b><br>Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. &nbsp;</p><p>Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team &nbsp;</p><p>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.&nbsp;</p><p>Excellent time management and priority-setting skills.</p><p>Maintains strict member confidentiality and complies with all HIPAA requirements.</p><p>Strong verbal and written communication skills. &nbsp; &nbsp;</p><p><b>Preferred:</b><br>Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM.&nbsp;</p><p>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.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4>Certified Case Manager (CCM)American Case Management Association (ACM)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Required:</b><br>Attend mandatory department trainings as scheduled</p><p>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.</p><p>Types of Shift: &nbsp;Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am).&nbsp;<br>Float (Varies)*<br>*All possible shifts.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, ICU, Emergency Medicine, Physical Therapy, Healthcare                                                    </p>

Utilization Management Admissions Liaison RN II

<h4><em><strong>How you'll change lives</strong></em></h4><p>As a Registered Nurse (RN) at US Renal Care, you'll be an integral part of a cross-functional team, working under the supervision of a Charge Nurse and assisting and supervising Patient Care Technicians (PCTs) to care for patients living with kidney disease.</p><h4><em><strong>What you'll be doing</strong></em></h4><p><strong>Patient care.</strong> You'll work directly with patients to provide safe, comfortable, and high-quality dialysis treatment. Responsibilities include completing and documenting physical assessments before and after treatments and monitoring patients during treatment. You'll ensure quality renal care by completing monthly reviews of patient medication profiles and administering medications according to physician orders. </p><p><strong>Teamwork.</strong> You'll be a critical member of an interdisciplinary team to provide all required patient assessment and care planning activities. You'll also make sure center staffing requirements are met at all times under the direction of the Administrator and according to state regulations for staffing ratios.</p><p><strong>Safety &amp; Quality.</strong> Working under the supervision of a Charge Nurse, you'll adhere to all company policies and procedures and state and federal laws and regulations. You'll participate in all required staff meetings and continuing education offerings.</p>

Dialysis Registered Nurse

<p>USRC's greatest strength in being a leader in the dialysis industry is our ability to recognize and celebrate the differences in our diverse workforce. We strongly believe in recruiting top talent and creating a diverse and inclusive work climate and culture at all levels of our organization.</p><ul><li><strong>A Home Therapy nurse trains home hemo or peritoneal dialysis patients in-center and sometimes in the patient’s home.</strong></li><li><strong>We Will Train - In-center hemodialysis, critical care, and home health are great backgrounds.&nbsp; </strong></li><li><strong>Work Schedule – Monday through Friday, 8am to 5pm; Modified schedules are possible based on patient caseload at the facility.</strong></li><li><strong>Competitive on-call pay when placed in on-call rotation. </strong></li><li><strong>Holidays – Home Training Nurses rarely work on a holiday. </strong></li><li><strong>We lead the industry in clinical quality improvement, delivering amongst the best patient outcomes in the U.S. as measured by the CMS ESRD Quality Incentive Program.</strong></li><li><strong>We remain an industry leader in home dialysis with 17% of dialysis treatments delivered in our patients' homes.&nbsp;</strong></li></ul><p>The Home Therapy Registered Nurse, as qualified by federal and state regulations, provides patient training and ongoing support for all patients choosing a home dialysis modality.&nbsp; This position is accountable for providing quality care to all patients and is committed to delivering superior customer service in all internal and external interactions.&nbsp;&nbsp;<br>&nbsp;<br>ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.&nbsp; Other duties and tasks may be assigned.</p><ul><li>Knowledge of and comply with federal, state, local laws and regulations, including health care professionals practice act requirements as they pertain to home dialysis program and patient care requirements.</li><li>Train patient (and/or care partner) in the practice of self-care Peritoneal Dialysis or Hemodialysis upon meeting federal and state regulations governing Registered Nurse qualifications.</li><li>Conduct home visits to assess the patient's home environment per policy; initially and minimally annually thereafter.&nbsp; Routinely evaluate patient performance and assess the home environment more frequently as needed to improve care.</li><li>Communicate results of patient assessment, reassessment, and ongoing monitoring to the physician, team members, and others as appropriate to the individual needs of the patient.</li><li>Document all nursing services in the Electronic Medical Record including but not limited to training sessions, routine and non-routine in-person interactions, and phone conversations.&nbsp; Documentation should accurately reflect the patient status and nursing interventions and be written to ensure continuity of care.</li><li>Participate in infection control monitoring, implementation, and recording as requested.</li><li>Be familiar with emergency equipment and all emergency operational procedures.&nbsp; Communicate and regularly review Emergency Preparedness procedures with all home patients, including but not limited to emergency disconnection from dialysis equipment, what to do and who to contact if displaced from home.</li><li>Ensure clinic and patient supply inventory and usage is appropriate for patient prescriptions and place orders in timely manner to avoid fees and penalties.</li><li>Continually seek to improve patient and quality outcomes through tracking and trending of program and patient performance, use of critical thinking skills and root cause analysis to improve patient and quality outcomes.&nbsp; Assist in obtaining data for the continuous quality improvement activities.</li><li>Obtain routine and non-routine laboratory tests as ordered and communicate critical lab values and urgent patient needs to the responsible physician or physician extender in a timely manner.</li><li>Complete and document monthly review of patient medication profiles.&nbsp; Administer medications as ordered by the physician.</li><li>Responsible for performing on call nursing services, nights and weekends, on a rotational basis as needed or assigned.</li><li>Flexible with staffing locations and hours to accommodate patient and USRC home program needs.</li><li>Regular and reliable attendance is required for the position.</li></ul><p>Home Hemodialysis Only:</p><ul><li>Coordinate home evaluation with technical services department to ensure that the necessary electrical, plumbing and drainage requirements for proper equipment operation are met prior to patient acceptance into home program.</li><li>Ensure required and appropriate water sampling is complete per policy and product requirements.&nbsp; Monitor and report water sample and culture results.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</li></ul><p><strong>Salary / Compensation Statement</strong></p><p><em>Compensation for the role will depend on several factors, including a candidate's experience, qualifications and skills. U.S. Renal Care offers a comprehensive total rewards package, which includes a 401k match, healthcare coverage, and a broad range of other benefits.</em></p>

Dialysis Registered Nurse, Peritoneal RN - We Will Train!

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>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.<br><br>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.<br></p><h4>Job Summary</h4><p>The Manager, Appeals &amp; Grievances (A&amp;G) &amp; General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals &amp; Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business. Provides direct supervision to the A&amp;G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies &amp; Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards.<br><br>The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement.</p><p>This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals.</p><p>Manages all aspects of running an efficient &nbsp;team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.&nbsp;</p><h4>Duties</h4><p>Manage and oversee the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity.<br><br>Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider grievances.</p><p>Responsible for timely daily operations in the A&amp;G Clinical Services Unit and other general operations units. &nbsp;Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with cross-functional departments &nbsp;to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate. &nbsp;</p><p>Lead, participate and provide representation of the A&amp;G Team at Internal and External meetings/ workgroups and acts as the point person for A&amp;G Programs especially the Clinical Programs.</p><p>Develop and execute on strategic opportunities to improve the overall appeals &amp; grievance process. Create a best in clinical appeals process that is efficient and effective in managing member appeals.</p><p>Work cross functionally and collaboratively within Appeals and Grievances with key internal partners to build a high functioning, results oriented environment and organization.&nbsp;</p><h4>Duties Continued</h4><p>Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships. Identify areas of connection to leverage and create added value for L.A. Care.</p><p>Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff.</p><p>Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes. &nbsp;Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management. &nbsp;</p><p>Identify and implement continuous business process improvement recommendations to leverage organizational added value to the Appeals and Grievances Department. &nbsp;Develop and implement short and long-term strategies to improve team results, reducing administrative expenses.</p><p>Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Supervision of the Clinical Services unit and general operations within Appeals and Grievances. Maintain a team of top talent, providing a culture of teamwork and collaboration.&nbsp;</p><p>Perform other duties as assigned</p><h4>Education Required</h4>Bachelor's Degree in Nursing<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b></p><p>6 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment and/or public services or public benefits programs.</p><p>At least 3 years of management level operations leadership experience.</p><p>Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations</p><p>Experience building relationships with organizations and business partners.</p><p><b>Equivalency:</b>&nbsp; Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.</p><p><b>Preferred:&nbsp; </b></p><p>Managed care experience.</p><h4>Skills</h4><p><b>Required:</b><br>Excellent analytical, problem solving, planning and implementation skills.</p><p>Demonstrated strong writing and communication skills.</p><p>Demonstrates excellent leadership, communication, and negotiation skills with the ability to interact and influence all levels of the organization including executive management and key decision -makers.</p><p>Demonstrates professional judgement, and critical thinking, to promote the delivery of quality, cost-effective care.</p><p>Time management and priority setting skills.</p><p>Excellent understanding of NCQA, DMHC, DOI, DHCS, and CMS regulatory requirements.</p><p>Knowledge of Coordination of Care, Medicare and Medi-Cal regulations, prior authorization, level of care and length of stay criteria sets.</p><p>Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.</p><p>Able to operate PC-based software programs including proficiency in Word, Excel and PowerPoint presentations.</p><p>Excellent verbal, written communication and presentation skills.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>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.</p><p>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</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Nurse Management, Medicaid, Medicare, Healthcare                                                    </p>

Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical)

<p><b>Salary Range:&nbsp;</b>&nbsp;$102,183.00&nbsp;(Min.) -&nbsp;$132,838.00&nbsp;(Mid.) -&nbsp;$163,492.00&nbsp;(Max.)</p><p>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.<br><br>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.<br></p><h4>Job Summary</h4><p>The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization Management projects. The position serves as a subject matter expert (SME), performing medical records reviews to include quality audits as well as validation of accuracy and completeness of all coding elements. The position is also responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development. This position trains and mentors Payment Integrity Nurse Coder, RN staff. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.</p><h4>Duties</h4><p>Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims.</p><p>Serves cross functionally with Utilization Management, Medical Directors, and other internal teams to assist in identification of overpayments as well as other projects.</p><p>Serves as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment Cost Avoidance. Identifies trends and patterns with overall program and individual provider coding practices.</p><p>Responsible for training and mentoring Payment Integrity Nurse Coder, RN staff.</p><p>Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success.</p><p>Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review.</p><p>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</p><p>Performs other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's Degree in Nursing<h4>Experience</h4><p><b>Required:</b></p><p>At least 8 years of clinical RN experience.</p><p>At least 3 years of experience in utilization management or clinical coding.</p><p>Investigation and/or auditing experience.</p><h4>Skills</h4><p><b>Required:</b></p><p>Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.</p><p>Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines.</p><p>Working knowledge of claims coding and medical terminology.</p><p>Solid understanding of standard claims processing systems and claims data analysis.</p><p>Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.</p><p>Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment.</p><p>Must be collaborative and have the ability to establish credibility quickly with all levels of management across multiple functional areas and be able to present findings across all departments.</p><p>Must be familiar with coordinating benefits between health plan payers.</p><p>Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California LicenseCertified Professional Coder (CPC) designation by the American Academy of Professional Codersand/orCertified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Medical Coding, Registered Nurse, Claims, Medicare, Healthcare, Insurance                                                    </p>

17 Nursing Jobs in California