RN Manager/Supervisor Utilization Review Full-time
L.A. Care Health Plan

Supervisor, Utilization Management RN

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Full-time
L.A. Care Health Plan

Lead Customer Solution Center Appeals and Grievances RN

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Lead Customer Solution Center Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit. This position is responsible for the quality review of complex and/or escalated clinical A&G cases for all line of business (LOB). The Lead will assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines. Leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion. Duties Review and process complex and/or escalated clinical A&G cases. Analyze the patient medical records, clinical documentation, and insurance policies to determine medical necessity. Prepares and reviews A&G files for submission to providers and internal departments. Work with other departments to ensure all aspects of a case are appropriately managed. Conduct targeted and random clinical case audits to ensure that all regulatory and departmental guidelines, policies, procedures, and standards are met. Work closely with the leadership team to create and/or modify Desk Level Procedures and recommends enhancements to process and procedures. Assist the Clinical Supervisors in identifying deviations in performance and process changes are implemented to redirect performance to acceptable levels. Recommend and implement resolutions, new processes, and/or process improvement. Provides accurate and timely written statistical reports that includes historical and/or current data to aid in projecting or evaluating compliance status. Identify and analyze trends in appeals and grievances to find the root cause of denials. Duties Continued Check, verifies and ensure that all clinical A&G cases are processed accurately and within established timelines to meet or exceed member satisfaction goals and regulatory (CMS, DMHC, DHCS, NCQA), Health and Safety Code and company compliance. Maintains documentation of all communications in the A&G system to ensure thorough tracking of case status. Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Work closely with management to review performance and quality standards on an ongoing basis. As well as motivational programs needed to achieve regulatory standards. Acts as a back-up to the Supervisor in leading meetings and handling escalations as required. Perform other duties as assigned. Education Required Associate's Degree in Nursing for Registered Nurses Education Preferred Bachelor's Degree in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting, At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment. At least 1 year of leading a process, program, or staff experience. Preferred: Clinical acute experience. Skills Required: Extensive knowledge of healthcare regulations and managed care guidelines Demonstrated ability to provide recommendations towards resolution. Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity. Ability to communication, conflict resolution, and motivational skills. Ability to work independently and closely with a team in a collaborative and interactive environment. Ability to adjust to changing circumstances within the team. Good verbal and written communication skills. Preferred: Strong project management skills with the ability to manage multiple training initiatives simultaneously. Licenses/Certifications Required Licensed Registered Nurse (RN) - Active, current and unrestricted California License and/or Physician Assistant (PA) - California License Required Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, and occasional flexibility in hours/shift in critical situations and work on-call. This position requires handling various caseloads and flexibility to adapt to changing priorities, which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Manager/Supervisor Full-time
L.A. Care Health Plan

Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical)

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.) ** Please note the following details for this role before applying: The candidate selected for this role MUST have recent experience with healthcare/managed care grievances The candidate selected for this role must live in California or be willing to relocate Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business. Provides direct supervision to the A&G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards. The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement. This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals. Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Manage and oversee the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider grievances. Responsible for timely daily operations in the A&G Clinical Services Unit and other general operations units. Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with cross-functional departments to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate. Lead, participate and provide representation of the A&G Team at Internal and External meetings/workgroups and acts as the point person for A&G Programs especially the Clinical Programs. Develop and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best in clinical appeals process that is efficient and effective in managing member appeals. Work cross functionally and collaboratively within Appeals and Grievances with key internal partners to build a high functioning, results oriented environment and organization. Duties Continued Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships. Identify areas of connection to leverage and create added value for L.A. Care. Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff. Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes. Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management. Identify and implement continuous business process improvement recommendations to leverage organizational added value to the Appeals and Grievances Department. Develop and implement short and long-term strategies to improve team results, reducing administrative expenses. Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Supervision of the Clinical Services unit and general operations within Appeals and Grievances. Maintain a team of top talent, providing a culture of teamwork and collaboration. Perform other duties as assigned Education Required Bachelor's Degree in Nursing Education Preferred Experience Required: 6 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment and/or public services or public benefits programs. At least 3 years of management level operations leadership experience. Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations Experience building relationships with organizations and business partners. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Preferred: Managed care experience. Skills Required: Excellent analytical, problem solving, planning and implementation skills. Demonstrated strong writing and communication skills. Demonstrates excellent leadership, communication, and negotiation skills with the ability to interact and influence all levels of the organization including executive management and key decision -makers. Demonstrates professional judgement, and critical thinking, to promote the delivery of quality, cost-effective care. Time management and priority setting skills. Excellent understanding of NCQA, DMHC, DOI, DHCS, and CMS regulatory requirements. Knowledge of Coordination of Care, Medicare and Medi-Cal regulations, prior authorization, level of care and length of stay criteria sets. Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. Able to operate PC-based software programs including proficiency in Word, Excel and PowerPoint presentations. Excellent verbal, written communication and presentation skills. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call. This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Admissions Liaison RN II

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) American Case Management Association (ACM) Required Training Physical Requirements Light Additional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Full-time
L.A. Care Health Plan

Payment Integrity Nurse Coder RN III

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization Management projects. The position serves as a subject matter expert (SME), performing medical records reviews to include quality audits as well as validation of accuracy and completeness of all coding elements. The position is also responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development. This position trains and mentors Payment Integrity Nurse Coder, RN staff. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff. Duties Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims. Serves cross functionally with Utilization Management, Medical Directors, and other internal teams to assist in identification of overpayments as well as other projects. Serves as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment Cost Avoidance. Identifies trends and patterns with overall program and individual provider coding practices. Responsible for training and mentoring Payment Integrity Nurse Coder, RN staff. Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success. Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review. Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 8 years of clinical RN experience. At least 3 years of experience in utilization management or clinical coding. Investigation and/or auditing experience. Skills Required: Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations. Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines. Working knowledge of claims coding and medical terminology. Solid understanding of standard claims processing systems and claims data analysis. Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously. Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment. Must be collaborative and have the ability to establish credibility quickly with all levels of management across multiple functional areas and be able to present findings across all departments. Must be familiar with coordinating benefits between health plan payers. Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Certified Professional Coder (CPC) designation by the American Academy of Professional Coders and/or Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA). Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
NP Full-time
L.A. Care Health Plan

Care Management Specialist II, D-SNP Team (ALD)

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Care Management Specialist II utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines. Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases, which are those with the severest acuities or care needs and requiring the highest clinical skills and judgement. Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner. Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit: Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team. Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Uses claims processing and care management software to look up member information, document contacts, and track member progress. Duties Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs. Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives; reviewing member claims histories and identifies intervention opportunities through the professional standards of practice; contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits; conducting comprehensive clinical assessments as indicated; developing a member centric plan of care. Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence). Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies. Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions. Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes. Duties Continued Meets and assesses members at L.A. Care Community Resource Centers, as needed. Provides effective care management for Individualized Care Plan summary and interventions during the Interdisciplinary Care Team meetings based on department guidelines. Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate. Encourages member and family empowerment through education and use of reliable resources. Monitors and evaluates member progress: evaluates member response to interventions and refines action plan to produce desired outcomes. Identifies complex care management issues and discusses possible solutions with management. Assesses effectiveness of care plan’s goals and interventions on a regular basis. Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member's clinical records to promote care coordination. Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage. Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training. Performs other duties as assigned. Education Required Associate's Degree in Nursing for Registered Nurses Master's Degree in Social Work for Licensed Clinical Social Workers Education Preferred Bachelor's Degree in Nursing for Registered Nurses Experience Required: Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments. Experience providing care management with complex/catastrophic conditions. Skills Required: Current knowledge of clinical standards of care and disease processes. Critical thinking skill. Excellent customer service skills. Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions. Ability to triage immediate member health and safety risks. Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping. Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders. Ability to use a personal computer, and knowledge of medical information systems. Knowledge of and ability to comply with HIPAA compliance. Ability to interview, assess and coordinate care. Ability to prioritize caseload. Knowledge of community resources. Knowledge of Medi-Cal and Medicare regulations. Ability to work as a part of a diverse team and gain consensus and resolution of problems. Preferred: Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese. Licenses/Certifications Required Registered Nurse (RN);current and unrestricted California License OR Licensed Clinical Social Worker; current and unrestricted California License. Licenses/Certifications Preferred Certified Case Manager (CCM) Accredited Case Manager (ACM) Certification Case Management Nurse – Board Certified (CMGT-BC) Required Training Physical Requirements Light Additional Information Required: Travel to offsite locations for work. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
NP Contract
L.A. Care Health Plan

Care Management Specialist II, D-SNP Team (12 month Assignment)

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Care Management Specialist II utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines. Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases, which are those with the severest acuities or care needs and requiring the highest clinical skills and judgement. Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner. Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit: Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team. Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Uses claims processing and care management software to look up member information, document contacts, and track member progress. Duties Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs. Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives; reviewing member claims histories and identifies intervention opportunities through the professional standards of practice; contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits; conducting comprehensive clinical assessments as indicated; developing a member centric plan of care. Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence). Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies. Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions. Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes. Duties Continued Meets and assesses members at L.A. Care Community Resource Centers, as needed. Provides effective care management for Individualized Care Plan summary and interventions during the Interdisciplinary Care Team meetings based on department guidelines. Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate. Encourages member and family empowerment through education and use of reliable resources. Monitors and evaluates member progress: evaluates member response to interventions and refines action plan to produce desired outcomes. Identifies complex care management issues and discusses possible solutions with management. Assesses effectiveness of care plan’s goals and interventions on a regular basis. Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member's clinical records to promote care coordination. Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage. Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training. Performs other duties as assigned. Education Required Associate's Degree in Nursing for Registered Nurses Master's Degree in Social Work for Licensed Clinical Social Workers Education Preferred Bachelor's Degree in Nursing for Registered Nurses Experience Required: Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments. Experience providing care management with complex/catastrophic conditions. Skills Required: Current knowledge of clinical standards of care and disease processes. Critical thinking skill. Excellent customer service skills. Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions. Ability to triage immediate member health and safety risks. Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping. Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders. Ability to use a personal computer, and knowledge of medical information systems. Knowledge of and ability to comply with HIPAA compliance. Ability to interview, assess and coordinate care. Ability to prioritize caseload. Knowledge of community resources. Knowledge of Medi-Cal and Medicare regulations. Ability to work as a part of a diverse team and gain consensus and resolution of problems. Preferred: Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese. Licenses/Certifications Required Registered Nurse (RN);current and unrestricted California License OR Licensed Clinical Social Worker; current and unrestricted California License. Licenses/Certifications Preferred Certified Case Manager (CCM) Accredited Case Manager (ACM) Certification Case Management Nurse – Board Certified (CMGT-BC) Required Training Physical Requirements Light Additional Information Required: Travel to offsite locations for work. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN OR Manager/Supervisor Full-time
L.A. Care Health Plan

Manager, Enhanced Care Management RN or LCSW

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary Reporting to the Director of Enhanced Care Management (ECM), the ECM Manager will be responsible for overseeing the day-to-day operations of both clinical and non-clinical ECM staff. The primary focus is on ensuring timely compliance and adherence to regulatory standards as outlined in the ECM Policy Guide, policies, and procedures. This position is responsible for enhancing care for the most vulnerable populations and actively participates in developing strategic approach to managing the ECM Team ensuring that it provide exceptional care management. This position extends to regulatory and accreditation compliance, as well as the oversight of ECM Providers and Plan Partners' delegated functions related to ECM. Collaborates with internal and external stakeholders, such as hospitals, providers, Local Initiatives, Plan Partners, and community-based organizations, is crucial to guaranteeing coordinated and cost-effective quality healthcare for L.A. Care Members. This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Duties Oversee ECM Provider Activities: Manage and ensure the effective and compliant performance of ECM Provider contracted activities. Cultivate and maintain active communication with ECM Providers, identifying performance issues and opportunities for improvement within the provider network that impact compliance and member care. Training and Collaboration: Collaborate with staff to identify topics and agenda items for Provider training and Joint Operating Meetings. Quality Assurance and Improvement: Ensure high-quality delivery of ECM services to medically and behaviorally complex members. Review systems and processes, making recommendations for improvement to consistently provide high-quality care. Comprehensively screen referred ECM member intakes to determine appropriate services and initiate care within established time frames. Establish and implement Quality Assurance mechanisms to measure and maintain high standards of care. Program Operations Enhancement: Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Develop and implement program operations enhancements. Ensure quality is measured and reporting requirements for state/federal compliance are met. Track data related to contract compliance and member complaints. Formulate reports and make recommendations to ensure overall program effectiveness through data collection and analysis. Duties Continued Community Engagement: Interact with other agencies and service providers in the community. Share information about services and resources. Help develop care-management strategies to enhance the delivery of ECM services. Team Leadership: Manage staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Address questions or issues raised by staff, encouraging them to provide recommendations for relevant process and systems enhancements. Compliance and Confidentiality: Maintain confidentiality in compliance with all HIPAA requirements. Communicate to supervisors any barriers to completing assignments or daily work efficiently and effectively. Demonstrate reliability and uphold good attendance and punctuality standards. Perform other duties as assigned. Education Required Master's degree in Social Work OR Associates Degree in Nursing In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Bachelor's Degree in Nursing or Related Field Experience Required: Minimum of 6 years of recent care management experience in a managed care setting, such as a health insurance environment and/or experience as care manager in a community based organization. At least 4 years of leading a process, program or staff or supervisory/management experience. Experience in Medi-Cal/Medicaid, Medicare, or other government medical programs for underserved populations Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Preferred: Previous care management experience in auditing/oversight/performance management. Skills Required: CalAIM Enhanced Care Management (ECM) Knowledge: Proficient understanding of CalAIM Enhanced Care Management (ECM) principles, policies, and processes. Strategic Partnership and Relationship Building: Acquaintance with the Los Angeles County ECM provider community, enabling effective strategic partnership development and establishment of enduring relationships. Healthcare Delivery and Finance: Knowledgeable about healthcare delivery and finance, with a keen understanding of its impact on the improving health outcomes. Audit and Oversight: Demonstrated experience in audit and oversight procedures. Communication Skills: Excellent verbal and written communication skills, and strong interpersonal skills. Proficiency in MS Office: Proficient in utilizing MS Office applications. Problem Solving: Ability to solve complex problems and identify creative solutions within the realm of healthcare management. Collaboration with External Agencies: Proven ability to address complex issues and identify creative solutions through collaboration with external agencies. Preferred: Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnam Licenses/Certifications Required Registered Nurse (RN);current and unrestricted California License OR Licensed Clinical Social Worker; current and unrestricted California License. Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information Please note that a Licensed Clinical Social Worker is only required when Master's Degree in Social Work. Licensed Clinical Social Worker not required with Associate's or Bachelor's Degree in Nursing. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Manager/Supervisor Utilization Review Full-time
L.A. Care Health Plan

Supervisor, Utilization Management RN

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Admissions Liaison RN II

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) American Case Management Association (ACM) Required Training Physical Requirements Light Additional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Manager/Supervisor Full-time
L.A. Care Health Plan

Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical)

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business. Provides direct supervision to the A&G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards. The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement. This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals. Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Manage and oversee the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider grievances. Responsible for timely daily operations in the A&G Clinical Services Unit and other general operations units. Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with cross-functional departments to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate. Lead, participate and provide representation of the A&G Team at Internal and External meetings/ workgroups and acts as the point person for A&G Programs especially the Clinical Programs. Develop and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best in clinical appeals process that is efficient and effective in managing member appeals. Work cross functionally and collaboratively within Appeals and Grievances with key internal partners to build a high functioning, results oriented environment and organization. Duties Continued Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships. Identify areas of connection to leverage and create added value for L.A. Care. Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff. Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes. Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management. Identify and implement continuous business process improvement recommendations to leverage organizational added value to the Appeals and Grievances Department. Develop and implement short and long-term strategies to improve team results, reducing administrative expenses. Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Supervision of the Clinical Services unit and general operations within Appeals and Grievances. Maintain a team of top talent, providing a culture of teamwork and collaboration. Perform other duties as assigned Education Required Bachelor's Degree in Nursing Education Preferred Experience Required: 6 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment and/or public services or public benefits programs. At least 3 years of management level operations leadership experience. Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations Experience building relationships with organizations and business partners. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Preferred: Managed care experience. Skills Required: Excellent analytical, problem solving, planning and implementation skills. Demonstrated strong writing and communication skills. Demonstrates excellent leadership, communication, and negotiation skills with the ability to interact and influence all levels of the organization including executive management and key decision -makers. Demonstrates professional judgement, and critical thinking, to promote the delivery of quality, cost-effective care. Time management and priority setting skills. Excellent understanding of NCQA, DMHC, DOI, DHCS, and CMS regulatory requirements. Knowledge of Coordination of Care, Medicare and Medi-Cal regulations, prior authorization, level of care and length of stay criteria sets. Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. Able to operate PC-based software programs including proficiency in Word, Excel and PowerPoint presentations. Excellent verbal, written communication and presentation skills. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call. This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Full-time
L.A. Care Health Plan

Managed Long Term Services and Supports Nurse Specialist RN II

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Managed Long-Term Services and Supports (MLTSS) Nurse Specialist RN II applies advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for L.A. Care members. Utilizes assessments, member-centered care planning, direct provider coordination/collaboration and psychosocial wraparound services to promote effective utilization of available Health Plan benefits including, but not limited to Community Based Adult Services (CBAS), Skilled Nursing Facility (SNF) services, Intermediate Care Facility for Developmentally Disabled (ICF/DD) services, CalAIM Community Supports, Palliative and Hospice Care. Scope of work includes care coordination functions and must adhere to regulatory mandates that apply to Utilization Management (UM) and Care Management (CM). This position is responsible for assessing, planning, coordinating, and monitoring care needs to ensure members receive high-quality, cost-effective care that promotes independence and quality of life. The MLTSS Nurse Specialist RN II conducts comprehensive health assessments and is a member of an interdisciplinary team that is key in identifying the physical, psychological and social needs of the member. The MLTSS Nurse Specialist RN II collaborates with Skilled Nursing Facilities (SNF), Intermediate Care Facility - Developmentally Disabled (ICF-DD), Community Based Adult Services (CBAS) Centers, Residential Care Facilities for the Elderly (RCFE), Preferred Provider Groups (PPG), CalAIM providers (i.e. Community Supports Vendors), Palliative and Hospice Care Providers and cross functional units to facilitate coordination of services. Duties Responsible for performing assessments and clinical review of medical records to determine appropriate care including physical health, behavioral health, and social determinants of health needs for members referred to; MLTSS administered programs. Responsible for UM authorization functions for services requiring prior authorizations in a timely manner with adherence to regulatory requirements. Identify and address gaps in care or overutilization, including overlapping services. Engages with members by conducting telephonic nursing follow up and care coordination when necessary, including transitions of care for Long Term Care (LTC) and ICF/DD populations. Provides direction to non-clinicians who assist members with accessing services and arranges for all services required while coordinating with the health care team to eliminate duplication of services. Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for MLTSS and other programs. Establishes relationships with referral sources and community resources, such as external providers and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Performs oversight and monitoring of provider performance for adherence to regulatory standards and contractual agreements. Participate in provider audits and quality improvement initiatives. Partners with Provider Network Management (PNM) and participates in Joint Operations Meetings (JOM). Duties Continued Facilitates care coordination with and provides education on available services to internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach minimizes member confusion, and ensures the best care is delivered in the most appropriate setting. Documents accurately and comprehensively based on the standards of practice and current organization policies. Performs other CM and UM functions as assigned and as needed /required by L.A. Care, to maintain regulatory requirements and company objectives. Performs other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 3 years of clinical nursing experience in direct patient care, such as ambulatory care, home care, palliative care, hospice care OR experience in Utilization Review or Care Management will be considered in lieu of direct patient care that may include at least 2 years of relevant Licensed Vocational Nurse (LVN) experience in a UM or CM capacity substituted for 1 year of RN experience. Clinical experience working with individuals with chronic illnesses, comorbidities, and/or disabilities in a UM/CM environment. Preferred: Experience in utilization review, skilled nursing, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agencies. Skills Required: Excellent verbal and written communication skills; with effective charting practices. Excellent organizational, time-management and priority-setting skills. Strong clinical skills with a knowledge of care needs for elderly, disabled, and/or frail populations and has applied knowledge of End-of-Life care. Customer Service Skills: Provision of excellent customer service required due to frequent communication with providers, members and interdisciplinary team. Technical Skills: Must be computer literate and proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint, Teams). Ability to effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System. Ability to maintain strict member confidentiality and complies with all HIPAA requirements. Preferred: Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information Required: Travel to offsite locations for work. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Full-time
L.A. Care Health Plan

Payment Integrity Nurse Coder RN III

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization Management projects. The position serves as a subject matter expert (SME), performing medical records reviews to include quality audits as well as validation of accuracy and completeness of all coding elements. The position is also responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development. This position trains and mentors Payment Integrity Nurse Coder, RN staff. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff. Duties Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims. Serves cross functionally with Utilization Management, Medical Directors, and other internal teams to assist in identification of overpayments as well as other projects. Serves as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment Cost Avoidance. Identifies trends and patterns with overall program and individual provider coding practices. Responsible for training and mentoring Payment Integrity Nurse Coder, RN staff. Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success. Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review. Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 8 years of clinical RN experience. At least 3 years of experience in utilization management or clinical coding. Investigation and/or auditing experience. Skills Required: Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations. Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines. Working knowledge of claims coding and medical terminology. Solid understanding of standard claims processing systems and claims data analysis. Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously. Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment. Must be collaborative and have the ability to establish credibility quickly with all levels of management across multiple functional areas and be able to present findings across all departments. Must be familiar with coordinating benefits between health plan payers. Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Certified Professional Coder (CPC) designation by the American Academy of Professional Coders and/or Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA). Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)