Utilization Management Specialist, RN

Job Category:  Clinical
Department:  Medical Management (640)
Location: 

Los Angeles HQ, California, US

Position Type:  Full Time
Requisition ID:  358

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 Transition of Care Nurse Specialist, RN  is primarily responsible for the overall coordination of the planned and unplanned transitions for the L.A. Care Health Plan members.  Responsibilities include implementing the program elements utilizing the current technology, ensuring regulatory and accreditation compliance, perform utilization and outcome reporting.  The position  is also responsible for assuring all functions are operating in accordance with the organization's mission, values and strategic goals; are focused on continuous implemented and provided in a manner that is responsive and culturally sensitive.  
The position is responsible for the day to day referral management of members transitioned to the Transitional Care Program.  This includes the timely and accurate determination and notification for pre-service, referral requests; generation of the appropriate specific member communications. As part of the process, the Transitional Care Nurse Specialist will be the consistent person responsible for supporting and managing members or the member's representative through planned and unplanned transitions of care settings. 

QUALIFICATIONS AND REQUIREMENTS

EDUCATION

Required
Associate's Degree or Bachelor's Degree in RN

LICENSES/CERTIFICATIONS
Required:
Registered Nurse (RN)
Current and unrestricted CA RN License
Valid California Driver's license

Preferred
Cert. in Case Management

EXPERIENCE
Required
5 years Clinical RN experience; with 3 years Utilization Management experience at HMO, hospital or PPG level particularly in review of inpatient or sub-acute admissions.
Previous experience with NCQA, Managed Care Medical and Medicare regulations
Excellent verbal and written communication skills 
Excellent interpersonal skills 
Good working knowledge of regulatory requirements/standards 
Proficiency with MS Word, Excel, and PowerPoint
Ability to work independently
Ability to solve complex issues and identify creative solutions

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

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


Job Segment: Nursing, Medical, Registered Nurse, Medicare, Healthcare