UM Nurse Specialist (RN II) – Care Management

L.A. Care

Lancaster (CA)

On-site

USD 89,000 - 142,000

Full time

4 days ago

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Benefits offered by this job

Paid Time Off

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Job summary

LA Care Health Plan in Los Angeles, CA is seeking a Utilization Management Nurse Specialist RN II. This role coordinates referrals, conducts reviews, and collaborates with staff to ensure timely discharge planning and appropriate care.

The candidate will monitor admissions, manage communications with providers, and support med review processes with the UM Manager and Physician Advisor. A California RN license and several years in hospital-based UR/CM are required.

Qualifications

Associate's Degree in Nursing required.
Active California RN license required.
At least 5 years of varied RN clinical experience in an acute hospital setting.
At least 2 years in Utilization Management/Case Management in hospital or HMO.
Managed Medi-Cal, Medicare, and commercial lines experience preferred.
Knowledge of NCQA requirements for UM/CM and DHCS/CMS requirements is a plus.

Responsibilities

Facilitates, coordinates, and approves medically necessary referrals meeting criteria.
Generates approval, modification, and denial communications to members and providers.
Monitors admissions and conducts telephonic/on-site reviews; assists with discharge planning.
Communicates within defined timelines per department policy.
Handles complex provider calls and follow-up with timely resolutions.
Maintains data in the platform/system of record.