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L.A. Care Health Plan Logo L.A. Care Health Plan · Nursing

Utilization Management Claims Review Nurse Rn Ii

United States, Los Angeles Employment contract 88854.00 - 142166.00 USD / Year · Job Posted May 16, 2026
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Job Description

The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards. This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA).

Job Responsibility

  • Perform claims pre-payment review
  • Conduct comprehensive retrospective reviews
  • Complete Provider Dispute Review (PDR) clinical evaluations
  • Apply internal and external clinical policies
  • Monitor trends related to contested claims and identify potential FWA concerns
  • Collaborate with internal teams to support payment integrity initiatives
  • Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions
  • Maintain productivity and quality standards
  • Participate in audits, regulatory readiness activities, and quality improvement initiatives
  • Document review outcomes clearly and accurately
  • Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements
  • Perform other duties as assigned

Requirements

  • Associate's Degree in Nursing
  • At least 5 years of experience in Clinical Nursing
  • At least 3 years of experience with Medi-Cal and Medicare in a managed care environment
  • Experience in performing and creating clinical documentation
  • Experience in regulatory compliance for a health plan
  • Registered Nurse (RN) - Active, current and unrestricted California License
  • Knowledge of medical necessity criteria, reimbursement principles, and managed care operation
  • Working knowledge of clinical policies
  • Working knowledge of CPT/HCPC Codes, and ICD-10
  • Proficient in claims processing systems and electronic medical record platforms
  • Strong problem-solving skills
  • Strong verbal and written communication skills
  • Ability to work independently
  • Ability to work effectively with diverse teams
  • Ability to multitask
  • Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA)
  • Understanding of the managed care industry
  • High organizational and time-management skills

Nice to have

  • Bachelor's Degree in Nursing
  • Experience with Provider Dispute Review (PDR) processes
  • Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes
  • Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring
  • Strong analytical and investigative skills
  • Advanced knowledge of medical necessity criteria tools such as InterQual or MCG
  • Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations

What we offer

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