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 in five health plans, we make sure our members get the right care at the right place at the right time.
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.
The Utilization Management Nurse Specialist RN II will facilitate, coordinate and approve of medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status.
Generates approval, modifications and denials communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan.
Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes.
Provides the primary clinical point of contact for the Community Access Network FRC in their assigned community. Ensures that L.A.
Care CAN Utilization Management goals met, and in a manner consistent with enhancing positive business growth. Functions as the clinical SME for all MSO-level activities.
Performs prospective, concurrent, post-service and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills and 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 cases needing Physician Advisor (PA) review or input. Presents cases to PA for potential review or determinations when needed.
Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan.
Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.
Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.
Identifies and initiates referrals for appropriate members to the various L.A.
Care programs/processes and external community based programs or Linked and Carve Out Services (e.g.
DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A.
Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director.
Perform other duties as assigned.
Associate's Degree in Nursing
Bachelor's Degree in Nursing
At least 5-7 years of varied clinical experience in an acute hospital setting. At least 2 years Utilization Management experience in a hospital or HMO setting. At least 2 years CM experience in a home health, hospice, or HMO setting.
Managed Care experience performing UM and CM at a Participating Physical Group (PPG) or MSO.
Experience with Managed Medi-Cal, Medicare, and commercial lines of business.
Experience with special needs populations.
Additional years of preferred experience could be substituted for missing required years of experience.
Technical skills: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint.
Customer Service Skills:
Provision of excellent customer service will be key to the success of this role and the CAN project.
Utilizes medical knowledge and experience to facilitate consensus building and development of satisfactory outcomes using persuasion skills.
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.
Registered Nurse (RN) - Active, current and unrestricted California License
Active & Current Driver's License, with a clean record and Auto Insurance Required
Certified Case Manager (CCM)
Location: May be out of the office at least 50% of the workday, driving to various locations, which may include but are not limited to: local acute care facilities and SNFs, physician offices, member homes, and other locations where members may be present.
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.
Care offers a wide range of benefits including
Paid Time Off (PTO)
Medical, Dental and Vision
Volunteer Time Off (VTO)
Care, we value our team members' safety.
In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A.
Care location each day. L.A.
Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A.
Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.
Nearest Major Market: Los Angeles
Job Segment: Nursing, Medical, Claims, Clinic, Medicare, Healthcare, Insurance
L.A. Care Health Plan