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Job Saved Save Job

Utilization Management & Quality Review Nurse

UCLA

Details

Posted: 07-Feb-25

Location: Los Angeles, California

Categories:

General Nursing

Internal Number: 146149100

Description

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

Qualifications

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

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About UCLA

At UCLA Health, you can help heal humankind, one patient at a time by improving health, alleviating suffering and delivering acts of kindness. As you do, you’ll achieve great things in your life and your career. We’re a world-class health organization with four hospitals consistently recognized among the nation’s very best as well as an internationally-renowned medical school, primary and specialty care clinics and much more. Within our dynamic, innovative and growing organization, you’ll find exceptional opportunities to make the most of your abilities in a supportive, empowering and inclusive environment. If you embrace our values of Integrity, Compassion, Respect, Teamwork, Excellence and Discovery we invite you to see all you can accomplish at UCLA Health.

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