RN II: Utilization Management & Clinical Quality Reviewer

L.A. Care; Los Angeles (CA); On-site; USD 89,000 - 142,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Job summary

L.A. Care Health Plan in California is seeking an Utilization Management Clinical Quality Nurse Reviewer RN II to lead audits, ensure regulatory compliance, and support external audits.

This role focuses on UM cases across lines of business to improve audit outcomes and service quality. The position requires an Associate's Degree in Nursing, California RN license, and 5+ years in clinical nursing with auditing experience; preferred Bachelor's or Master’s in Nursing, and strong communication and

Qualifications

• Requires RN license in California.
• At least 5 years of clinical nursing experience.
• Minimum 2 years of auditing clinical documentation.
• Experience with Medi-Cal and Medicare in a managed care environment.
• Active participation in regulatory audits (state and federal).
• Strong communication and analytical skills.

Responsibilities

• Audit and track internal department documentation.
• Lead pre- and post-audit preparation and follow-up.
• Develop and review policies to ensure regulatory compliance.
• Identify opportunities to improve audit outcomes and service quality.
• Present quality metrics and risk assessments to leadership.
• Collaborate with Compliance and QA teams on audits.

Skills

Verbal and written communication

Analytical thinking

Team building

Independent work

Multitasking

Regulatory translation

Education

Associate's Degree in Nursing

Bachelor's Degree

Master's Degree in Nursing

Tools

Microsoft Word

Excel

Job description

L.A. Care Health Plan in California is seeking an Utilization Management Clinical Quality Nurse Reviewer RN II to lead audits, ensure regulatory compliance, and support external audits.

This role focuses on UM cases across lines of business to improve audit outcomes and service quality. The position requires an Associate's Degree in Nursing, California RN license, and 5+ years in clinical nursing with auditing experience; preferred Bachelor's or Master’s in Nursing, and strong communication and