Utilization Management RN: Claims Review & Care Compliance
L.A. Care Health Plan
L.A. Care Health Plan in Los Angeles, CA is seeking a Utilization Management (UM) Claims Review Nurse RN II to evaluate medical claims for medical necessity, documentation, and proper coding. This role supports payment integrity through pre-payment and retrospective reviews and ensures compliance with state, federal, and accreditation standards. The position requires an RN with at least 5 years in clinical nursing, 3 years in Medi-Cal/Medicare managed care, and knowledge of CPT/HCPC codes and #J-18808-Ljbffr L.A. Care Health Plan
Vacancy posted 4 days ago
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...That Drives Quality, Compliance, and Exceptional Patient Care Are you an... ...with a passion for utilization management, operational excellence... ...Improvement, Claims, Network Development... ...Registered Nurse (RN) license in the state... ..., please review the Know Your Rights...ClaimsContract workWork at officeMonday to FridayWeekend work3 days per week- ...Group is seeking a qualified Utilization Management Nurse to review patient records and craft... ...letters, ensuring accuracy and compliance. You will support OPAS and... ...reviews. Requirements include an RN license, 3+ years bedside nursing in acute care, and proficiency with...Remote jobWork at officeFlexible hours
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...solutions, and comprehensive care navigation together in... ...is a moment where your review decides what happens... ...what keep the entire utilization review process trustworthy... ...reviews: Evaluate post-claim and post-service... ...the next level of care. Manage the appeals process: Process...ClaimsHourly payMonday to Friday- Manager of Case Management at Surgery Partners, Inc. leads the case management team with a strong focus on utilization review, ensuring compliant care and reducing unnecessary hospital stays. This role collaborates... .... Requirements include RN license with BSN, UR/UR-related...
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