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<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 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.</p><h4>Duties</h4><p>Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.</p><p>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. </p><p>Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.</p><p>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.</p><p>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. </p><p>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.</p><h4>Perform other duties as assigned. </h4><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>At least 5 years of varied RN clinical experience in an acute hospital setting.</p><p>At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting .&nbsp;</p><p><b>Preferred:</b><br>Managed Care experience performing UM and CM at a medical group or management services organization.</p><p>Experience with Managed Medi-Cal, Medicare, and commercial lines of business.</p><h4>Skills</h4><p><b>Required:</b><br>Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. &nbsp;Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate &nbsp;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>Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team &nbsp;<br><br>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 Care Management (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)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>May work on occasional weekends and some holidays depending on business needs.</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, Medicare, Medicaid, Claims, Healthcare, Insurance                                                    </p>

L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

<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 Lead Customer Solution Center Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&amp;G) clinical unit.</p><p>This position is responsible for the quality review of complex and/or escalated clinical A&amp;G cases for all line 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. </p><p>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.</p><h4>Duties</h4><p>Review and process complex and/or escalated clinical A&amp;G cases. Analyze the patient medical records, clinical documentation, and insurance policies to determine medical necessity. Prepares and reviews A&amp;G files for submission to providers and internal departments.</p><p>Work with other departments to ensure all aspects of a case are appropriately managed.</p><p>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 recommends enhancements to process and procedures. </p><p>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. </p><p>Provides accurate and timely written statistical reports that includes 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.</p><h4>Duties Continued</h4><p>Check, verifies and ensure that all clinical A&amp;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.</p><p>Maintains documentation of all communications in the A&amp;G system to ensure thorough tracking of case status.</p><p>Leads 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.</p><p>Acts as a back-up to the Supervisor in leading meetings and handling escalations as required.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Associate's Degree in Nursing for Registered Nurses<h4>Education Preferred</h4>Bachelor's Degree in Nursing for Registered Nurses<h4>Experience</h4><p><b>Required:</b></p><p>At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting,</p><p>At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment.</p><p>At least 1 year of leading a process, program, or staff experience.</p><p><b>Preferred:</b></p><p>Clinical acute experience.</p><h4>Skills</h4><p><b>Required:</b></p><p>Extensive knowledge of healthcare regulations and managed care guidelines</p><p>Demonstrated ability to provide recommendations towards resolution.</p><p>Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity.</p><p>Ability to communication, conflict resolution, and motivational skills. </p><p>Ability to work independently and closely with a team in a collaborative and interactive environment.</p><p>Ability to adjust to changing circumstances within the team. </p><p>Good verbal and written communication skills.</p><p><b>Preferred:</b></p><p>Strong project management skills with the ability to manage multiple training initiatives simultaneously.</p><h4>Licenses/Certifications Required</h4>Licensed Registered Nurse (RN) - Active, current and unrestricted California License and/or Physician Assistant (PA) - California License Required<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, and 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, Medical, Registered Nurse, Medicare, Medicaid, Healthcare                                                    </p>

Lead Customer Solution Center Appeals and Grievances RN

<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>

3 Nursing Jobs in Los Angeles, CA, USA