RN II: Utilization Management & Clinical Quality Reviewer

L.A. Care Health Plan; Idaho; On-site; USD 89,000 - 142,000; Full time

Benefits offered by this job

PTO

Tuition reimbursement

Retirement plans

Medical, dental and vision

Wellness program

Volunteer Time Off (VTO)

Job summary

L.A. Care Health Plan in Idaho seeks a Utilization Management Clinical Quality Nurse Reviewer RN II to join the UM Department. You will conduct internal audits of UM documentation and serve as a SME during external audits.

Requirements include an active California RN license, Associate's Degree in Nursing, 5+ years clinical nursing, 2+ years auditing, and experience with Medi‑Cal/Medicare in managed care. Strong analytical and communication skills are essential.

Qualifications

• Associate's Degree in Nursing required.
• Active RN license in California.
• Minimum 5 years in Clinical Nursing.
• Minimum 2 years auditing clinical documentation.
• Experience with Medi-Cal and Medicare in managed care.
• Participation in state and federal regulatory audits.

Responsibilities

• Audit internal UM documentation for compliance.
• Lead audit preparation and follow-up.
• Develop and review policies to ensure regulatory compliance.
• Generate quality reports and monitor KPI trends.
• Collaborate with leadership to drive quality improvements.
• Serve as consultant to Compliance team.

Skills

Communication skills

Analytical skills

Teamwork

Multitasking

Problem-solving

Independent worker

Education

Associate's Degree in Nursing

Bachelor's Degree

Master's Degree in Nursing

Tools

Microsoft Word

Microsoft Excel

Microsoft Office

Job description

L.A. Care Health Plan in Idaho seeks a Utilization Management Clinical Quality Nurse Reviewer RN II to join the UM Department. You will conduct internal audits of UM documentation and serve as a SME during external audits.

Requirements include an active California RN license, Associate's Degree in Nursing, 5+ years clinical nursing, 2+ years auditing, and experience with Medi‑Cal/Medicare in managed care. Strong analytical and communication skills are essential.