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<p><b>Salary Range:&nbsp;&nbsp;<b><b><b><b>$88,854.00</b></b></b></b>&nbsp;(Min.) -&nbsp;<b><b><b><b>$132,838.00</b></b></b></b>&nbsp;(Mid.) -&nbsp;<b><b><b><b>$163,492.00</b></b></b></b>&nbsp;(Max.)</b></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 II will learn and obtain certification in coding as well as perform medical records reviews to include quality audits, provide validation of accuracy and completeness of all coding elements. This role 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 will also be responsible for participating in Payment Integrity initiatives to include concept and cost avoidance development.</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>Learns and becomes knowledgeable in 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>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>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 Degree in Nursing<h4>Experience</h4><p><strong>Required:</strong><br>At least 5-7 years clinical experience and a minimum of 2 years in utilization management or clinical coding.</p><h4>Skills</h4><p><strong>Required</strong>:<br>Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.</p><p>Investigation and/or auditing experience.</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 License<h4>Licenses/Certifications Preferred</h4>Certified Professional Coder (CPC) designation by the American Academy of Professional CodersCertified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).<h4>Required Training</h4><p><strong>Required:&nbsp;</strong><br>Responsible for completing an approved certified coding course within six months of date of hire.</p><p>Responsible for completing Coding Certification of above approved course work within one year of date of hire.</p><h4>Physical Requirements</h4><h4>Additional Information</h4><p><strong>Required:</strong><br>Responsible for obtaining Certified Professional Coder (CPC) designation by the American Academy of Professional Coders.</p><p>Current Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA) within one year of date of hire.</p><p><strong>Salary Range Disclaimer:</strong> 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><br><strong>L.A. Care offers&nbsp;a wide range of benefits including</strong></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>                    Medical Coding, Nursing, Registered Nurse, Claims, Medicare, Healthcare, Insurance                                                    </p>

L.A. Care Health Plan

Payment Integrity Nurse Coder RN II

<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

RN Charge Nurse

<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>

Payment Integrity Nurse Coder RN III

<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

<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

Dialysis Registered Nurse MWF

<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 Managed Long-Term Services and Supports (MLTSS) Nurse Specialist RN II applies advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for L.A. Care members. Utilizes assessments, member-centered care planning, direct provider coordination/collaboration and psychosocial wraparound services to promote effective utilization of available Health Plan benefits including, but not limited to Community Based Adult Services (CBAS), Skilled Nursing Facility (SNF) services, Intermediate Care Facility for Developmentally Disabled (ICF/DD) services, CalAIM Community Supports, Palliative and Hospice Care. Scope of work includes care coordination functions and must adhere to regulatory mandates that apply to Utilization Management (UM) and Care Management (CM). </p><p>This position is responsible for assessing, planning, coordinating, and monitoring care needs to ensure members receive high-quality, cost-effective care that promotes independence and quality of life.&nbsp; The MLTSS Nurse Specialist RN II conducts comprehensive health assessments and is a member of an interdisciplinary team that is key in identifying the physical, psychological and social needs of the member.&nbsp; </p><p>The MLTSS Nurse Specialist RN II collaborates with Skilled Nursing Facilities (SNF), Intermediate Care Facility - Developmentally Disabled (ICF-DD), Community Based Adult Services (CBAS) Centers, Residential Care Facilities for the Elderly (RCFE), Preferred Provider Groups (PPG), CalAIM providers (i.e. Community Supports Vendors), Palliative and Hospice Care Providers and cross functional units to facilitate coordination of services. </p><h4>Duties</h4><p>Responsible for performing assessments and clinical review of medical records to determine appropriate care including physical health, behavioral health, and social determinants of health needs for members referred to; MLTSS administered programs.</p><p>Responsible for UM authorization functions for services requiring prior authorizations in a timely manner with adherence to regulatory requirements. Identify and address gaps in care or overutilization, including overlapping services.</p><p>Engages with members by conducting telephonic nursing follow up and care coordination when necessary, including transitions of care for Long Term Care (LTC) and ICF/DD populations.&nbsp; </p><p>Provides direction to non-clinicians who assist members with accessing services and arranges for all services required while coordinating with the health care team to eliminate duplication of services. </p><p>Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for MLTSS and other programs. </p><p>Establishes relationships with referral sources and community resources, such as external providers and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements.&nbsp; </p><p>Performs oversight and monitoring of provider performance for adherence to regulatory standards and contractual agreements. Participate in provider audits and quality improvement initiatives. Partners with Provider Network Management (PNM) and participates in Joint Operations Meetings (JOM). &nbsp;</p><h4>Duties Continued</h4><p>Facilitates care coordination with and provides education on available services to internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach minimizes member confusion, and ensures the best care is delivered in the most appropriate setting. </p><p>Documents accurately and comprehensively based on the standards of practice and current organization policies.</p><p>Performs other CM and UM functions as assigned and as needed /required by L.A. Care, to maintain regulatory requirements and company objectives. </p><p>Performs other duties as assigned.&nbsp;</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></p><p>At least 3 years of clinical nursing experience in direct patient care, such as ambulatory care, home care, palliative care, hospice care OR experience in Utilization Review or Care Management will be considered in lieu of direct patient care that may include at least 2 years of relevant Licensed Vocational Nurse (LVN) experience in a UM or CM capacity substituted for 1 year of RN experience.</p><p>Clinical experience working with individuals with chronic illnesses, comorbidities, and/or disabilities in a UM/CM environment. </p><p><b>Preferred:</b></p><p>Experience in utilization review, skilled nursing, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agencies.</p><h4>Skills</h4><p><b>Required:</b></p><p>Excellent verbal and written communication skills; with effective charting practices. </p><p>Excellent organizational, time-management and priority-setting skills.</p><p>Strong clinical skills with a knowledge of care needs for elderly, disabled, and/or frail populations and has applied knowledge of End-of-Life care. </p><p>Customer Service Skills:&nbsp; Provision of excellent customer service required due to frequent communication with providers, members and interdisciplinary team.</p><p>Technical Skills: Must be computer literate and proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint, Teams).&nbsp; Ability to effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System.</p><p>Ability to maintain strict member confidentiality and complies with all HIPAA requirements.</p><p><b>Preferred:&nbsp;</b></p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.</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><br><b>Required:</b><br>Travel to offsite locations for work.</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>                    LVN, Nursing, Travel Nurse, Behavioral Health, Patient Care, Healthcare                                                    </p>

Managed Long Term Services and Supports Nurse Specialist RN II

<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>

Utilization Management Nurse Specialist RN II

<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>

17 Social Services Jobs in California