Utilization Management RN II — Claims Review & Compliance

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

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