Utilization Management RN II — Care Coordination

L.A. Care Health Plan; Los Angeles (CA); On-site; USD 89,000 - 142,000; Full time

Benefits offered by this job

PTO

Tuition Reimbursement

Retirement Plans

Medical / Dental / Vision

Wellness Program

Volunteer Time Off

Job summary

L.A. Care Health Plan in Los Angeles, CA seeks an Utilization Management Nurse Specialist RN II to coordinate and approve referrals that meet criteria.

You will monitor inpatient admissions, conduct telephonic or onsite reviews, and collaborate with on-site staff to discharge patients effectively. Ideal candidate has 5+ years RN experience, 2+ years UM/CM in hospital or HMO, and CA RN license; Bachelor's in Nursing preferred.

Qualifications

• RN degree and active California license required.
• Minimum 5 years varied RN experience in acute hospital.
• Minimum 2 years UM/CM in hospital or HMO setting preferred.
• Managed Medi-Cal, Medicare and commercial lines knowledge may help.
• NCQA DHCS CMS familiarity is a plus.

Responsibilities

• Facilitate, coordinate, and approve medically necessary referrals.
• Generate approval, modification and denial communications to members and providers.
• Monitor admissions in inpatient settings and perform concurrent reviews.
• Collaborate with staff, physicians, and members to discharge plans.
• Work with UM Manager and Physician Advisor on case reviews.
• Process and document referrals and data transfers in the system.
• Serve as department resource for referral management and provider contacts.
• Receive provider calls and resolve inquiries with timely responses.
• Follow up to provide response or resolution steps in a professional manner.

Skills

Communication

Computer literacy

HIPAA compliance

Time management

Customer service

Verbal & written comms

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 Utilization Management Nurse Specialist RN II to coordinate and approve referrals that meet criteria.

You will monitor inpatient admissions, conduct telephonic or onsite reviews, and collaborate with on-site staff to discharge patients effectively. Ideal candidate has 5+ years RN experience, 2+ years UM/CM in hospital or HMO, and CA RN license; Bachelor's in Nursing preferred.