Utilization Management RN: Claims Review & Care Compliance

L.A. Care Health Plan; Los Angeles, Northern (CA, KY); Hybrid; 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 is seeking a Utilization Management (UM) Claims Review Nurse RN II to evaluate medical claims for medical necessity, documentation, and proper coding.

This role supports payment integrity through pre-payment and retrospective reviews and ensures compliance with state, federal, and accreditation standards. The position requires an RN with at least 5 years in clinical nursing, 3 years in Medi-Cal/Medicare managed care, and knowledge of CPT/HCPC codes and

Qualifications

• Knowledge of medical necessity criteria, reimbursement principles and managed care operation.
• Working knowledge of CPT/HCPC Codes and ICD-10.
• Proficient with claims processing systems and electronic medical record platforms.

Responsibilities

• Perform pre-payment review to ensure services are medically necessary and properly documented.
• Conduct retrospective reviews applying clinical criteria and regulatory guidelines.
• Complete Provider Dispute Review (PDR) evaluations for disputed claims.
• Ensure compliance with internal policies and external regulations to limit FWA.
• Monitor trends in contested claims and escalate findings.
• Collaborate with internal teams to support payment integrity initiatives.
• Provide clear clinical rationales for approvals, denials or adjustments.
• Maintain productivity and quality standards per department expectations.
• Participate in audits, regulatory readiness and quality improvement activities.
• Stay current with evolving clinical guidelines, coding standards and reimbursement methodologies.

Skills

Medical necessity criteria

Reimbursement principles

Managed care operations

Clinical policies

CPT/HCPCS & ICD-10

Claims processing systems

EMR platforms

Problem-solving

Verbal & written communication

Independent work

Cross-functional collaboration

Multitasking

Regulatory standards

Managed care market knowledge

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Job description

L.A. Care Health Plan in Los Angeles, CA is seeking a Utilization Management (UM) Claims Review Nurse RN II to evaluate medical claims for medical necessity, documentation, and proper coding.

This role supports payment integrity through pre-payment and retrospective reviews and ensures compliance with state, federal, and accreditation standards. The position requires an RN with at least 5 years in clinical nursing, 3 years in Medi-Cal/Medicare managed care, and knowledge of CPT/HCPC codes and