Utilization Management Claims Review Nurse RN II

Working Nurse; Los Angeles (CA); On-site; USD 89,000 - 142,000; Full time

Job summary

Working Nurse in Los Angeles, CA, is seeking a Utilization Management Claims Review Nurse RN II to conduct clinical reviews of medical claims ensuring medical necessity, proper documentation, and accurate billing. The role supports payment integrity through retrospective and pre-payment reviews and ensures compliance with regulatory standards.

The ideal candidate has at least 5 years of clinical nursing experience and 3+ years handling Medi-Cal/Medicare in a managed care setting, with strong

Qualifications

• Associate's Degree in Nursing required.
• Bachelor's Degree in Nursing preferred.
• At least 5 years of experience in Clinical Nursing.
• At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.
• Experience in performing and creating clinical documentation; experience with regulatory compliance for a health plan.

Responsibilities

• The UM Claims Review Nurse RN II conducts clinical review of medical claims to ensure services are medically necessary, properly documented, and accurately billed.
• Supports payment integrity initiatives through retrospective and pre-payment review processes, aiming to reduce denials.
• Collaborates with internal teams and external entities to ensure compliance with state, federal, and accreditation requirements.

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Job description

RN Job

Utilization Management Claims Review Nurse RN II

Shift

Full Time

Pay Range

$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)

Job ID

13266

Location

Los Angeles, 90017

Apply at Website

Email Recruiter

Job Description

The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards.

This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA).

The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements.

Qualifications

Education Required

• Associate's Degree in Nursing

Education Preferred

• Bachelor's Degree in Nursing

Experience Required

• At least 5 years of experience in Clinical Nursing.
• At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.
• Experience in performing and creating clinical documentation.Experience in regulatory compliance for a health plan.

Preferred

• Experience with Provider Dispute Review (PDR) processes.
• Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes.
• Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring.

About The Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?

Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.