What are the responsibilities and job description for the Utilization Management & Quality Review Nurse position at UCLA Health?
General Information Press space or enter keys to toggle section visibility Work Location : Los Angeles, USA Onsite or Remote Flexible Hybrid Work Schedule Monday-Friday, 8 : 00am-5 : 00pm PST Posted Date 10 / 30 / 2024 Salary Range : $61.79 - 79.91 Hourly Employment Type 2 - Staff : Career Duration Indefinite Job # 20147 Primary Duties and Responsibilities Press space or enter keys to toggle section visibility As the Utilization Management & Quality Review Nurse, you will be responsible for :
- Ensuring appropriate, cost-effective, and high-quality care for New Century Health Plan members
- Conducting utilization management (UM) activities in accordance with health plan policies and regulatory guidelines
- Identifying and reporting Potential Quality Issues (PQI) and supporting Provider Dispute Resolution (PDR) processes to ensure compliance and foster provider satisfaction
- Completing other duties as assigned Salary Range : $61.79 - $79.91 / hourly Job Qualifications Press space or enter keys to toggle section visibility We're seeking a highly qualified candidate with :
- A BSN or MSN degree, required
- Current valid California RN license, required
- Two or more years of experience in utilization management, preferably in Medicare Advantage or managed care
- Knowledge of Medicare Advantage regulatory guidelines, including CMS regulations
- Experience with Potential Quality Issues (PQI) identification and reporting
- Familiarity with Provider Dispute Resolution (PDR) processes
- Strong clinical assessment and critical thinking skills
- Proficiency in electronic health records (EHR) and utilization management software
- Excellent written and verbal communication skills As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.
Salary : $62 - $80
