Utilization Management RN: Care Coordination & Appeals

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 Los Angeles, CA seeks an RN II for Utilization Management to coordinate and approve medically necessary referrals, monitor admissions, and communicate determinations to members and providers.

You will work with the UM Manager and Physician Advisor on case reviews and ensure proper documentation in the system of record. The role requires an RN with at least 5 years of acute care experience and 2 years in UM/CM, strong computer skills (Outlook/Word/Excel/PowerPoint), and a

Qualifications

• At least 5 years of varied RN clinical experience in an acute hospital setting.
• At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting.
• Managed Care UM/CM experience is preferred.
• Experience with Medi-Cal, Medicare and commercial lines.

Responsibilities

• Promote and coordinate timely referrals and communications.
• Perform telephonic/on-site admission and concurrent review.
• Develop and implement discharge plans with on-site staff and physicians.
• Monitor data collection and documentation in the system of record.
• Address inquiries from providers professionally and provide timely resolutions.

Skills

Time management

Communication

HIPAA knowledge

Customer service

Team collaboration

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Outlook

Word

Excel

PowerPoint

Job description

L.A. Care Health Plan in Los Angeles, CA seeks an RN II for Utilization Management to coordinate and approve medically necessary referrals, monitor admissions, and communicate determinations to members and providers.

You will work with the UM Manager and Physician Advisor on case reviews and ensure proper documentation in the system of record. The role requires an RN with at least 5 years of acute care experience and 2 years in UM/CM, strong computer skills (Outlook/Word/Excel/PowerPoint), and a