Utilization Management Nurse Specialist RN II Job at L.A. Care Health Plan (Los Angeles)

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service required
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations
Generates approval, modification and denial communications
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review
Collaborates with onsite staff, physicians, providers, member/family to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews
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
Receives incoming calls from providers, professionally handles complex calls

What we offer

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

Fulltime

Care Management Specialist II, D-SNP Team

The Care Management Specialist II utilizes clinical skills and training to perfo...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing for Registered Nurses OR Master's Degree in Social Work for Licensed Clinical Social Workers
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
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

Job Responsibility

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
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
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

What we offer

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

Fulltime

New

Lawson Senior AP Processor

THE ACCOUNTS PAYABLE PROCESSOR WILL SUPPORT DAILY AP OPERATIONS ACROSS BOTH PO A...

Location

United States , Houston

Salary:

60.00 USD / Hour

Medasource

Expiration Date

Until further notice

Requirements

LAWSON (INFOR) EXPERIENCE REQUIRED
EXCEL PROFICIENCY REQUIRED
DEMONSTRATED ABILITY TO MANAGE HIGH-VOLUME INVOICE PROCESSING
HEALTHCARE AP EXPERIENCE REQUIRED FOR PO-SIDE ROLES
HEALTHCARE EXPERIENCE NOT REQUIRED FOR NON-PO ROLE
STRONG CUSTOMER SERVICE AND VENDOR COMMUNICATION SKILLS
BACHELOR’S DEGREE PREFERRED OR EQUIVALENT WORK EXPERIENCE

Job Responsibility

PROCESS AND VALIDATE PO-BASED INVOICES WITHIN LAWSON
OWN THE 3-WAY MATCH (PO, RECEIVING, INVOICE)
RESEARCH AND RESOLVE PRICE DISCREPANCIES, MISSING RECEIPTS, AND VENDOR ISSUES
PARTNER CLOSELY WITH SUPPLY CHAIN / MATERIALS MANAGEMENT TO RECONCILE EXCEPTIONS
MANAGE VENDOR INQUIRY MAILBOXES AND COMMUNICATION
HANDLE VENDOR DISCUSSIONS ON REBATES, DISCOUNTS, AND PAYMENT TERMS (NET 1–15)
UTILIZE GHX PORTAL FOR EDI ELECTRONIC INVOICE PROCESSING
PROVIDE MENTORSHIP TO JUNIOR PROCESSORS AND SUPPORT CONTINUOUS IMPROVEMENT
MANAGE EXPENSE REPORTS, ELECTRONIC PAYMENTS, AND NON-PO INVOICE PROCESSING
PROCESS REIMBURSEMENTS THROUGH INFOR XM

What we offer

competitive medical, dental, vision, Health Savings Account, Dependent Care FSA, and supplemental coverage
401k plan that includes a company match and is fully vested after you become eligible
paid time off, sick time, and paid company holidays
Employee Assistance Program (EAP) that provides services like virtual counseling, financial services, legal services, life coaching

New

Accounting Clerk

We are looking for a detail-oriented Accounting Clerk to join our team in Bakers...

Location

United States , Bakersfield

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Minimum of 3 years of experience in accounting or a related role
Proficiency in accounts receivable (AR) and accounts payable (AP) processes
Strong knowledge of QuickBooks and other accounting software
Exceptional attention to detail and accuracy in data entry
Ability to process invoices efficiently and with precision
Solid understanding of journal entries and bank reconciliations
Effective organizational and time management skills
Associate degree in accounting, business, or a related field preferred

Job Responsibility

Process accounts receivable transactions, including invoicing and payment tracking
Handle occasional accounts payable duties, ensuring accurate and timely payments
Maintain and update accounting databases to ensure data integrity
Record journal entries and assist with general ledger maintenance
Reconcile cash receipts and bank accounts to ensure financial accuracy
Review and process invoices, verifying details for completeness and accuracy
Perform data entry tasks to support accounting operations
Collaborate with team members to ensure seamless financial workflows
Utilize QuickBooks for managing and tracking financial activities

What we offer

medical
vision
dental
life and disability insurance
401(k) plan

New

Cook

Hartwell Lodge Care Home in Fareham is looking for an experienced Cook or Chef t...

Location

United Kingdom , Fareham

Salary:

12.72 GBP / Hour

Buckland Care

Expiration Date

Until further notice

Requirements

Several years of experience in hospitality/catering is required
Level 2 Food & Hygiene is required
A City & Guilds Catering qualification would be ideal but is not a requirement
Passionate about food, local produce and fresh ingredients
Good level of English
A good team player
Excellent time management skills
Prioritising resident and relative needs and offering personalised menus when required
Honest and kind person who can work under pressure
Previous experience in a care home is beneficial

Job Responsibility

Work to create inspiring mealtimes for residents at the home, catering to all preferences and dietary requirements
Enjoy interacting and communicating with the elderly as there will be regular contact with our residents
Have up to date knowledge of food health and hygiene
Knowledge on fortified diets and soft diets, but we can train you on this if need be

New

Occupational Therapist

Inabia is seeking an experienced Occupational Therapist to join its Rehab Therap...

Location

United States , Robert Lee

Salary:

Not provided

Inabia Solutions & Consulting

Expiration Date

Until further notice

Requirements

Active Texas Occupational Therapist license (required)
SNF experience preferred
No new graduates (experience required)
Strong documentation, communication, and patient-care skills

Job Responsibility

Evaluate patients’ functional abilities related to ADLs, mobility, cognition, and safety
Develop and implement individualized occupational therapy treatment plans
Provide skilled therapy services in accordance with physician orders and facility protocols
Educate patients and caregivers on adaptive techniques and equipment
Monitor patient progress and adjust plans of care as needed
Document evaluations, daily treatments, and discharge summaries accurately and timely
Collaborate with interdisciplinary team members to support patient outcomes

What we offer

Consistent weekday daytime schedule
Manageable patient caseload
Opportunity to work in a focused SNF rehab environment
Supportive interdisciplinary team

Fulltime

New

Materials Attendant

This job description indicates the general nature and level of work expected of ...

Location

United States , Aurora

Salary:

19.80 - 29.70 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

High School Graduate
No experience required
Ability to operate and understand basic computer functions, data entry systems and devices
Must be able to stand and walk for extended periods of time, have ability to lift, bend, squat, and twist the majority of the workday and crawl, kneel, and climb throughout
Must be able to lift up to 15 lbs. from floor to overhead
Must be able to lift up to 50 lbs. from floor to waist
Must be able to lift and carry up to 50 lbs. at waist height a reasonable distance
Must be able to push/pull with 20 lbs. of force
Operates all equipment necessary to perform the duties of the job including but not limited to data entry into Material Management Computer System, data entry into hand-held computers, operation of material handling machinery (i.e., Reach trucks, order pickers, pallet movers)

Job Responsibility

Receives incoming materials and equipment and inspects/verifies the accuracy and the condition of the items before signing for the delivery
Ensures efficient and accurate record-keeping systems to verify receipt, storage and distribution of supplies and equipment
Prepares, distributes and transports supplies and equipment for safe and appropriate distribution to facilities, departments, or other entities as required
Provides for the timely distribution of all supplies and equipment in response to issue requisitions, customer requests, defined replenishment schedules and purchase orders
Warehouses and maintains inventory levels and performs issues and credits for supplies and equipment as necessary
Replenishes and maintains specialty carts, trays and kits (Code Carts, Isolation Carts, Lime Trays, etc.) checking for outdated supplies as necessary
Ensures proper preparation, packaging, initiation of return, and any required follow-up to returned material to vendors as instructed by appropriate documentation
Maintains security, orderliness, and cleanliness in all working areas while providing for the continual checking, rotation and removal of outdated and/or damaged materials

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Parttime

Utilization Management Nurse Specialist RN II

L.A. Care Health Plan

Location:
United States , Los Angeles

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 05, 2026

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