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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
About UCLA
More Jobs from This Employer
https://careers.apha.org/jobs/21048319/utilization-management-quality-review-nurse
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