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Utilization Management & Quality Review Nurse
UCLA
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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

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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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