Utilization Management Oversight Nurse Specialist (Per Diem)

Job Category:  Clinical
Department:  Clinical Assurance (646)
Location: 

Los Angeles HQ, California, US

Position Type:  Per-Diem
Requisition ID:  355

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.

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.

DUTIES: 
The Utilization Management Specialist Position ensures compliance of the participating physician groups (PPGs) with regulatory, contractual and LA Care requirements. The UM Specialist is responsible for performing annual and focused audits and continuous monitoring activities. This position also acts as a liaison between the PPGs and L. A. Care Health Plan regarding UM issues, and assists in improving access and utilization performance of PPGs by being a resource for best practices and providing continuous feedback.

Additionally, the oversight responsibility of this position includes attendance at PPG UM Committee and Joint Operational Meetings (JOMs), monitoring of supplemental UM reports, reporting to management and UM Committee (UMC) and consultation/instructional/coaching activities to improve overall compliance of PPGs with all regulations and standards.

QUALIFICATIONS AND REQUIREMENTS

EDUCATION: 
Required: 
Associate's Degree

Preferred:
Bachelor's Degree

LICENSES/CERTIFICATIONS
Required
Current and unrestricted CA RN License
Valid California driver's license and valid automobile insurance

Preferred
Cert. in Case Management

EXPERIENCE: 
Required:
5 years of previous experience in a managed care health plan performing UM oversight, including auditing.
Good working knowledge of regulatory requirements/standards.
Excellent verbal and written communication skills.
Excellent interpersonal skills.
Proficiency with MS Office Application, such as MS Word, Excel, and PowerPoint.
Ability to work independently.
Ability to solve complex issues and identify creative solutions.
Persuasion Skills: Ability to influence PPGs to improve compliance and performance.

L.A. Care offer a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program


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