RN II: Utilization Management & Clinical Quality Audits

L.A. Care Health Plan; United States; Remote; USD 89,000 - 142,000; Full time

Benefits offered by this job

Paid Time Off

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Volunteer Time Off

Job summary

L.A. Care Health Plan is seeking an experienced Utilization Management Clinical Quality Nurse Reviewer RN II to lead audits, ensure regulatory compliance, and support policy development. The role emphasizes data analysis, reporting, and collaboration with Compliance and UM leadership.

The RN must have strong documentation skills, CA RN license, and extensive experience with Medi-Cal/Medicare in managed care. This on-site role offers growth opportunities within the UM department.

Qualifications

• Required: At least 5 years of experience in Clinical Nursing.
• Minimum of 2 years of auditing clinical documentation.
• Active participation in at least two state regulatory audits and one federal regulatory audits.
• Experience with Medi-Cal and Medicare in a managed care environment; mitigation planning and implementation.

Responsibilities

• Facilitates development, review, and revision of processes to ensure regulatory compliance.
• Focuses on documentation practices and mandates applicable to UM functions.
• Generates findings and reports quality and accuracy of case documentation.
• Collaborates with leadership to identify opportunities for quality improvements.
• Presents quality reports to measure adherence to compliance standards.
• Keeps leadership apprised of trends, deficiencies, and risks; develops mitigation efforts.
• Consults with Compliance team on ad hoc basis.
• Performs other duties as assigned.

Skills

Communication skills

Excel proficiency

Analytical skills

Independent work

Team collaboration

Problem solving

Multitasking

Leadership in improvement projects

Education

Associate's Degree in Nursing

Bachelor's Degree

Master's Degree in Nursing

Tools

MS Word

Excel

Job description

L.A. Care Health Plan is seeking an experienced Utilization Management Clinical Quality Nurse Reviewer RN II to lead audits, ensure regulatory compliance, and support policy development. The role emphasizes data analysis, reporting, and collaboration with Compliance and UM leadership.

The RN must have strong documentation skills, CA RN license, and extensive experience with Medi-Cal/Medicare in managed care. This on-site role offers growth opportunities within the UM department.