Lancaster, Pennsylvania
Nashville, Tennessee
Los Angeles, California
Carmel, Indiana
Raleigh, North Carolina
Posted: 08-Mar-25
Location: Los Angeles, California
Categories:
Internal Number: 146580864
Take on a high-impact role within a world-class health organization. Help drive the continued delivery of exceptional patient care. Take your career to the next level. You can do all this and more at UCLA Health.
You will play a key part in promoting high-quality, cost-effective medical care by applying clinical acumen and applicable policies and guidelines in the issuance of adverse organization determinations. You will review for appropriate care and setting while working closely with denial coordinators and other staff to ensure the accurate processing of all written notifications. You will also provide clinical guidance on denial cases and ensure that all denial letters are written and issued according to internal policies and NCQA, health plan, federal, and state requirements.
Salary Range: $63,800 - $127,000/annually
- Current CA LVN licensure required
- Two or more years of utilization review/utilization management experience in an HMO, MSO, IPA, or health plan environment
- Previous clinical experience
- Experience drafting and issuing compliant adverse organization determinations
- In-depth knowledge of health plan, DMHC, CMS, HIPPA, and NCQA requirements
- Expertise in abstracting and interpreting medical information from patient records
- Strong communication, interpersonal, analytical, problem-solving, organizational, and prioritizing skills
- Thorough understanding of the Hierarchy of Clinical Criteria
- Experience with Flesch-Kincaid readability scoring
- Knowledge of the appeals process
- Experience with audit preparation
- Basic computer skills
