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<p>The <strong>RN Charge Nurse</strong> is responsible for overseeing nursing services each shift and functions as a nursing supervisor. This position provides daily supervision of staff on duty during operational hours.</p><p>Essential Duties and Responsibilities include the following. Other duties and tasks may be assigned.</p><ul><li> Assist with clinical and operational processes to improve patient health and minimize hospitalizations and missed treatments.</li><li> Demonstrate effective use of supplies and staff labor hours.</li><li> Complete and document monthly review of patient medication profiles. Administer medications as ordered by the physician.</li><li> Assist physician during patient rounds and transcribe and implement physician orders timely.</li><li> Assist with the implementation of anemia management and medication protocols as requested.</li><li> Knowledge of and comply with federal, state, local laws and regulations, including health care professionals practice act requirements.</li><li> Perform duties at all times within limitations established by and in accordance with company policy and procedures, applicable state and federal laws and regulations.</li><li> May give direct patient care to the extent of performing efficient, safe dialysis, if allowed by state regulations.</li><li> Responds to all emergencies in clinic.</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> Maintain collaborative working relationship with Medical Director and physicians.</li><li> Participate as a member of the Interdisciplinary team in all required patient assessment and care planning activities.</li><li> Assist in orientation of new staff as a preceptor or in assigning a preceptor.</li><li> Acts as resource person and participates in implementing and evaluating dialysis services and assures that policies and procedures are updated.</li><li>Assists Administrator in interviewing, hiring, evaluating, and disciplinary actions of center staff</li></ul>

U.S. Renal Care

Dialysis Registered Nurse - Charge

<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><strong>Qualified candidates with prior peritoneal dialysis or hemodialysis experience may be eligible for up to $7,500 signing bonus - please inquire!</strong>&nbsp;</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>Essential Duties and Responsibilities include the following. Other duties and tasks may be assigned.</p><p>GROWTH</p><p>· Participate in and support corporate initiatives that promote improved care and increase growth of the home department.</p><p>· Understand vendor product delivery methods and associated fees. Teach patients the importance of proper and timely order placement. Ensure patients receive all supplies in timely manner to not disrupt care.</p><p>· Assist with clinic and patient supply inventory, ensuring usage is appropriate for patient prescriptions and place orders in timely manner to avoid fees and penalties. </p><p>· May assist with equipment management including equipment tracking and retrieval as needed.</p><p>· Perform duties as assigned to meet the patient care or operational needs of the program.</p><p>OUTCOMES</p><p>· May assist with improving patient 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. May assist in obtaining data for the continuous quality improvement activities.</p><p>· 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.</p><p>· May complete and document monthly review of patient medication profiles as directed. Administer medications as ordered by the physician.</p><p>· Provide patient education and follow up as needed.</p><p>· Assist with program's target goals for patient outcomes in accordance with quality patient care and Company goals.</p><p>OPERATIONAL</p><p>READINESS</p><p>OPERATIONAL</p><p>READINESS</p><p> (cont.)</p><p>· 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.</p><p>· Perform duties at all times within limitations established by and in accordance with company policy and procedures, applicable state and federal laws and regulations.</p><p>· 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.</p><p>· May conduct home visits to assess the patient's home environment per policy and as needed to improve care.</p><p>· Inform (Direct Supervisor) and program Administrator of all incidents, conditions, and concerns related to patient care, staff and patient safety, and in accordance with company policy.</p><p>· 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. Documentation should accurately reflect the patient status and nursing interventions and be written to ensure continuity of care.</p><p>· May assist with developing and implementing the patient plan of care with the interdisciplinary team.</p><p>· Participate in infection control monitoring, implementation, and recording as requested.</p><p>· Use personal protective equipment as necessary.</p><p>· Be familiar with emergency equipment and all emergency operational procedures. 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.</p><p>· Communicate on-call system to patients and ensure patients have access to nursing support at all times. Teach patients the importance of timely communication.</p><p>· May perform on call nursing services, nights and weekends, on a rotational basis as needed or assigned.</p><p>· Flexible with staffing locations and hours to accommodate patient and USRC home program needs.</p><p>· Regular and reliable attendance is required for the position.</p><p>Home Hemodialysis Only:</p><p>· May 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.</p><p>· May assist with ensuring required and appropriate water sampling is complete per policy and product requirements. Monitor and report water sample and culture results.</p><p>PARTNERSHIPS</p><p>· 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.</p><p>· Maintain a positive/collaborative working relationship with physicians, state agencies and the community.</p><p>· Actively promote GUEST customer service standards; develop effective relationships at all levels of the organization.</p><p>· Respond effectively to inquiries or concerns.</p><p>STAFF DEVELOPMENT/ RETENTION</p><p>· Participate in staff meetings as required. Attend in-service and continuing education offerings in compliance with company policy and procedure.</p><p>· May delegate tasks to competent licensed and unlicensed staff per applicable state practice act.</p><p>· Assist with staff training as requested.</p><p>· Lead staff in team concepts and promote a team effort.</p>

Dialysis Registered Nurse, Home Hemo & Peritoneal RN - Floater **Sign-On Bonus up to $7,500**

Dialysis Registered Nurse MWF

<p>Salary Range:&nbsp;&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 in five health plans, 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 Clinical Assurance Compliance Nurse Specialist RN II is responsible for the review of regulatory, contractual and accreditation standards to ensure Health Care Services Department policies are in compliance and in operation. The position works closely with Regulatory Affairs and Compliance to ensure timely exchange of documentation to evidence compliance. The position is responsible for the internal auditing process for referral management and complex case management using approved auditing/monitoring tools. This position participates in the review and presentation when necessary of training materials for external delegates and internal staff training.&nbsp;</p><h4>Duties</h4><h4>Assist in the continual maintenance of Health Services Policies/Procedures, letter templates, Workflows, Process, Audit Tools and Training Materials in compliance with regulatory requirements, new legislation and accreditation standards. Work collaboratively with Regulatory Affairs &amp; Compliance to ensure Health Services Departments are made aware and department documents updated accordingly.</h4><h4>Develop and maintain Medical Management training materials in compliance with all regulatory requirements, new legislation, and accreditation standards. Assist in the preparation of the Health Services Departments for review by external regulatory and accrediting bodies (Department of Health Care Services (DHCS), A&amp;I, DHCS Member Rights, Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services(CMS)) and internally for audits by Real Application Clusters (RAC) through team processes. </h4><h4>Assist in the development and revisions of audit tools, Policies, provider trainings to improve compliance with regulatory and accreditation standards. Develop and implement procedures to assurance compliance with care coordination and documentation of Utilization Management (UM) and CM element.</h4><h4>Provide training, education and consultation as necessary to delegates. Collaborate with other UM staff on identifying topics and developing agendas for the JOMs/performance visits/communications. </h4><h4>Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assist co-workers with special projects or work volume as required. Actively identify and implement efforts to improve the quality, effectiveness and efficiency of job functions.&nbsp;&nbsp; </h4><h4>Communicate to supervisors any barriers to completing assignments or daily work with delegates in an efficient and effective manner. Demonstrate reliability and good attendance and punctuality standards.</h4><p>Perform 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>Required:</p><p>At least 5 years of experience in a clinical setting and managed care plan performing UM oversight, including auditing.</p><p>Managed Health Care experience.</p><h4>Skills</h4><p>Required:</p><p>Good working knowledge of licensure and regulatory requirements, and accreditation standards.</p><p><br>Ability to manage and organize large volumes of data.</p><p>Knowledge of regulatory and accreditation entities and their requirements.</p><p>Excellent verbal and written communication skills; excellent interpersonal skills.</p><p>Proficient in MS Office applications.</p><p>Ability to work independently. Ability to solve complex problems/issues and identify creative solutions.</p><p>Knowledge of issues pertaining to Medi-Cal, Medicare, and other Health Maintenance Organization (HMO) &amp; Independent Practice Association (IPA) contracts and payers.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4>Certified Professional in Utilization Review (CPUR)Certified Case Manager (CCM)Certified Professional in Healthcare Quality (CPHQ)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

L.A. Care Health Plan

Clinical Assurance Compliance Nurse Specialist RN II

<p>Salary Range:&nbsp;&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 in five health plans, 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 Clinical Quality Nurse Reviewer RN II, under the purview the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role is ensures that UM practices and supporting documentation are compliant with all regulatory requirements. &nbsp;The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up.&nbsp; This position actively participates in development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position will focus 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 create reports on audit findings, as well as make recommendations, to submit to the department's Quality Assurance Team and UM Management.</p><h4>Duties</h4><p>Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines.</p><p>Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions.</p><p>Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation.&nbsp;</p><p>Works with department leadership to assess for all opportunities related to quality improvements.&nbsp;</p><p>Compiles and presents quality report cards that measure adherence to quality and regulatory compliance.&nbsp;</p><p>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.</p><p>Serves as a consultant to the organization's Compliance team on an ad hoc basis.</p><p>Performs other duties as assigned.&nbsp;</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's Degree in Nursing<h4>Education Preferred</h4>Bachelor's DegreeMaster's Degree in Nursing<h4>Experience</h4><p>Required:&nbsp;<br>At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. &nbsp;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.</p><p>Preferred: &nbsp;<br>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. &nbsp;Background in teaching and/or clinical education.</p><h4>Skills</h4><p>Required:&nbsp;<br>Superior verbal and written communication skills.&nbsp;</p><p>Advanced computer proficiency in both Microsoft Word and Excel.&nbsp;</p><p>Strong analytical and team building skills.&nbsp;</p><p>Ability to work independently and be self-directed.&nbsp;</p><p>Ability to work effectively with diverse team members.&nbsp;</p><p>Strong problem-solving skills.&nbsp;</p><p>Ability to multitask and streamline day-to-day operations.&nbsp;</p><p>Ability to translate regulatory requirements into auditable tools.&nbsp;</p><p>Preferred:</p><p>Proven ability to lead successful performance improvement projects.</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>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

Utilization Management Clinical Quality Nurse Reviewer RN II

<p>Come care with us at West Coast University! As a Nursing Faculty member for a certified Great Place to Work, you will guide nursing students to do more than change their own lives – you will help change the lives of every patient they treat throughout their career in healthcare. &nbsp;At West Coast University you will have the opportunity to share your success story with the next generation of nurses as a key member of our student-centered, innovative community!</p><p><strong>You will make an impact by: &nbsp;</strong></p><ul><li>Serving as a mentor, role model and facilitator who provides guidance and academic support for students.</li><li>Demonstrating enthusiasm for teaching, the teaching/learning process and for individual students.</li><li>Applying your skills and experience to your assigned teaching schedule.</li><li>Participating in and contributing to assessment activities of courses/curriculum and programs via a continuous improvement plan set forth by the University.</li><li>Regularly contributing to improvement of class materials and syllabi within prescribed shared governance culture.</li><li>Utilizing a variety of teaching methodologies to instruct students, always with intent to facilitate observable evidence of student fulfillment of prescribed learning outcomes.</li><li>Maintaining scholarly activities.</li><li>Participating in professional growth and service in accordance with university policies.</li><li>Advancing our commitment and focus on the students we serve, and their success as healthcare professionals.</li><li>Fully leveraging our innovative technologies and resources, such as our Simulation and Innovation Labs.</li><li>*If working with students in a Clinical setting you will:<ul><li>Assume complete responsibility for students in clinical facilities.</li><li>Clarify clinical expectations with students.</li><li>Clarify student placement and expectations with clinical facility staff.</li><li>Utilize care planning time to direct students to available resources needed for clinical preparation.</li><li>Assess student knowledge and skill level to ensure safety and optimal care to patients.</li><li>Utilize pre- and post- conference to allow students an opportunity to share learned experiences, ensuring clarity of the correlation between &nbsp;weekly theory content with clinical objectives and experiences.</li><li>Provide feedback of clinical performance immediately after observation of event and of overall performance at midterm and end of semester.</li></ul></li></ul><p><strong>Your Experience Includes: &nbsp;</strong></p><ul><li>Working knowledge of Microsoft Office Suite Products, especially Outlook, Word, PowerPoint and other MS office products as needed.</li><li>Working with online learning management systems to further engage the student learning process.</li><li>Compliance with state, federal and local laws/regulations relating to programs, governmental compliance, and other regulatory standards such as state Board of Nursing.</li><li>Clinical RN - Must have a minimum of two (2) year’s prior experience as a registered nurse providing direct patient care and have a minimum of one year experience in the field in which they teach.</li></ul><p><strong>Education:</strong> Education and experience must align with state regulations and comply with the rules and regulations of state authorization agencies.</p><ul><li>Master’s degree in nursing</li><li>Professional nurse licensure required.</li></ul><p>#HEJ</p><p>#LI-EB1</p>

West Coast University

OB Nurse Theory Instructor

<p>Come care with us at West Coast University! As a Nursing Faculty member for a certified Great Place to Work, you will guide nursing students to do more than change their own lives – you will help change the lives of every patient they treat throughout their career in healthcare. &nbsp;At West Coast University you will have the opportunity to share your success story with the next generation of nurses as a key member of our student-centered, innovative community!</p><p><strong>You will make an impact by: &nbsp;</strong></p><ul><li>Serving as a mentor, role model and facilitator who provides guidance and academic support for students.</li><li>Demonstrating enthusiasm for teaching, the teaching/learning process and for individual students.</li><li>Applying your skills and experience to your assigned teaching schedule.</li><li>Participating in and contributing to assessment activities of courses/curriculum and programs via a continuous improvement plan set forth by the University.</li><li>Regularly contributing to improvement of class materials and syllabi within prescribed shared governance culture.</li><li>Utilizing a variety of teaching methodologies to instruct students, always with intent to facilitate observable evidence of student fulfillment of prescribed learning outcomes.</li><li>Maintaining scholarly activities.</li><li>Participating in professional growth and service in accordance with university policies.</li><li>Advancing our commitment and focus on the students we serve, and their success as healthcare professionals.</li><li>Fully leveraging our innovative technologies and resources, such as our Simulation and Innovation Labs.</li><li>*If working with students in a Clinical setting you will:<ul><li>Assume complete responsibility for students in clinical facilities.</li><li>Clarify clinical expectations with students.</li><li>Clarify student placement and expectations with clinical facility staff.</li><li>Utilize care planning time to direct students to available resources needed for clinical preparation.</li><li>Assess student knowledge and skill level to ensure safety and optimal care to patients.</li><li>Utilize pre- and post- conference to allow students an opportunity to share learned experiences, ensuring clarity of the correlation between &nbsp;weekly theory content with clinical objectives and experiences.</li><li>Provide feedback of clinical performance immediately after observation of event and of overall performance at midterm and end of semester.</li></ul></li></ul><p><strong>Your Experience Includes: &nbsp;</strong></p><ul><li>Working knowledge of Microsoft Office Suite Products, especially Outlook, Word, PowerPoint and other MS office products as needed.</li><li>Working with online learning management systems to further engage the student learning process.</li><li>Compliance with state, federal and local laws/regulations relating to programs, governmental compliance, and other regulatory standards such as state Board of Nursing.</li><li>Clinical RN - Must have a minimum of two (2) year’s prior experience as a registered nurse providing direct patient care and have a minimum of one year experience in the field in which they teach.</li></ul><p><strong>Education:</strong> Education and experience must align with state regulations and comply with the rules and regulations of state authorization agencies.</p><ul><li>Master’s degree in nursing</li><li>Professional nurse licensure required.</li></ul>

Nurse Faculty

<br><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 PRN

<p>Salary Range:&nbsp;&nbsp;$67,186.00&nbsp;(Min.) -&nbsp;$87,342.00&nbsp;(Mid.) -&nbsp;$107,498.00&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 in five health plans, 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><br>The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals &amp; Grievance program for L.A. Care Health Plan members under the direct supervision and management of the A&amp;G Nurse Specialist, RN and/or Medical Director. This position provides assistance to members with health care access and benefit coordination issues, ensuring that clinical grievances and complex issues are investigated and resolved to the member’s satisfaction consistent with L.A. Care Health Plan and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care Health Plan Lines of Business.&nbsp;</p><h4>Duties</h4><p>Works with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD review and determination. Performs clinical review of medical records related to grievances and appeals. Responsible for handling member and provider appeals providing clinical reviews and write-ups and recommendations, mailing and faxing of resolution letters.</p><p><br>Reviews grievance cases that require immediate clinical quality of care, initial coding of member grievance and evaluation and/or require immediate pre-service authorization evaluation.</p><p>Investigates Provider Disputes/PDR and prepares clinical summary for Medical Director determination.&nbsp;</p><p>Work with the external providers and PPGs representatives to obtain relevant medical records and communication documentation.</p><p>Investigation and preparation of State Fair Hearing cases as assigned.</p><p>Prepare resolved complaint files for Centers for Medicare and Medicaid Services(CMS), external review organization (QIO or IRE).</p><p>Work with Utilization Management and PNO to facilitate completion of resolution determination.</p><p>Investigate, prepare summary and work with Medical Directors to resolve expedited cases within regulatory timelines. Maintain knowledge of regulatory changes related to all grievances and appeals and meets regulatory requirements. Refers cases for further follow-up or notification as appropriate, e.g. fraud and abuse cases shall be forwarded to Compliance Department.</p><p>Perform other duties as assigned.</p><h4>Duties Continued</h4><h4>Education Required</h4>Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><strong>Required:</strong><br>At least 4 years of clinical nurse and managed care experience.</p><h4>Skills</h4><p><br><strong>Required:</strong><br>Excellent interpersonal and communication skills.&nbsp;</p><p>Good working knowledge of regulatory requirements/standards.&nbsp;</p><p>Computer literacy and adaptability to computer learning.&nbsp;</p><p>Time management and priority setting skills.</p><p>Must be organized and a team player, able to work effectively with various internal business units, Plan Partners, participating provider groups, and external agencies.</p><h4>Licenses/Certifications Required</h4>Licensed Vocational Nurse (LVN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><p><strong>Required:</strong><br>License Vocational Nursing (LVN)</p><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>Salary Range Disclaimer: 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>L.A. Care offers&nbsp;a wide range of benefits including</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>

21 Social Services / Nursing Jobs in California