Utilization Management RN — Claims Review Pro

L.A. Care Health Plan; Lancaster (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

Job summary

L.A. Care Health Plan in Los Angeles, CA seeks a Utilization Management (UM) Claims Review Nurse RN II to conduct clinical reviews ensuring medical necessity, accurate documentation, and compliant billing.

You will collaborate with internal teams to support payment integrity, participate in audits, and stay current with CMS, Medi-Cal, and NCQA guidelines while maintaining high productivity and quality. Experience in pre-payment and retrospective reviews, plus knowledge of InterQual/MCG criteria,

Qualifications

• Associate's Degree in Nursing required.
• Bachelor's Degree in Nursing preferred.
• Minimum 5 years of clinical nursing experience.
• At least 3 years in Medi-Cal/Medicare managed care.
• Experience in clinical documentation and regulatory compliance.
• Experience with Provider Dispute Review (PDR) preferred.
• Experience applying clinical guidelines (InterQual/MCG) preferred.
• Knowledge of CPT/HCPCS and ICD-10.

Responsibilities

• Perform pre-payment review to ensure medical necessity and accurate coding.
• Conduct retrospective reviews applying clinical criteria and policies.
• Complete PDR clinical evaluations for disputed claims.
• Apply policies to limit fraud, waste, and abuse.
• Monitor trends in contested claims and escalation.
• Collaborate with internal teams to support payment integrity.
• Document clear clinical rationales for decisions.
• Maintain productivity and quality standards.
• Participate in audits and regulatory readiness activities.
• Stay current with evolving clinical guidelines and regulations.

Skills

Medical necessity

Reimbursement principles

Managed care

Clinical policies

CPT/HCPCS knowledge

ICD-10 terminology

EMR systems

Claims processing

Analytical skills

Communication skills

Education

Associate degree in Nursing

Bachelor's degree in Nursing

Tools

EMR platforms

Job description

L.A. Care Health Plan in Los Angeles, CA seeks a Utilization Management (UM) Claims Review Nurse RN II to conduct clinical reviews ensuring medical necessity, accurate documentation, and compliant billing.

You will collaborate with internal teams to support payment integrity, participate in audits, and stay current with CMS, Medi-Cal, and NCQA guidelines while maintaining high productivity and quality. Experience in pre-payment and retrospective reviews, plus knowledge of InterQual/MCG criteria,