- CenterWell (Sacramento, CA)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- UCLA Health (Los Angeles, CA)
- …clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, ... Description At UCLA Health, the Utilization Management ( UM ) Review Nurse plays a vital...contributes to performance improvement projects. + Remains current with clinical best practices and UM regulatory changes.… more
- Humana (Sacramento, CA)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... from medical records sent from Behavioral Health Facilities to obtain sufficient clinical information. The Utilization Management Behavioral Health Nurse 2 work… more
- Veterans Affairs, Veterans Health Administration (Redlands, CA)
- …Model .The Community Care RN Clinical Coordinator is supervised by the VACC Clinical Nurse Manager whose immediate supervisor is the Chief of Community Care. ... Summary The Community Care RN Clinical Coordinator is a registered professional nurse... Clinical Coordinator utilizes comprehensive knowledge of advanced clinical practice and UM principles to assess… more
- Humana (Sacramento, CA)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Cedars-Sinai (CA)
- **Job Description** Are you ready to bring your expert clinical skills to a world-class facility recognized as one of the top ten in the United States? Do you have a ... America's Best Hospitals. + You will serve as a clinical co-pilot-charting the best trajectory of each patient's care...with 2 or more year of care management experience ( UM or DC Planning). + Knowledge of medical literature,… more
- Cedars-Sinai (CA)
- **Job Description** Are you ready to bring your expert clinical skills to a world-class facility recognized as one of the top ten in the United States? Do you have a ... capabilities. **Summary of Essential Duties:** + Serve as a clinical co-pilot-charting the best trajectory of each patient's care...with 2 or more year of care management experience ( UM or DC Planning). At Cedars-Sinai, we are dedicated… more
- Highmark Health (Sacramento, CA)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and… more
- UCLA Health (Los Angeles, CA)
- Description We are seeking a highly skilled and dynamic Director of Clinical Services to lead the development, evaluation, and implementation of multiple clinical ... care. You will: + Oversee the development and execution of multiple UM processes and workflows, while continuously identifying and evaluating areas for improvement… more
- LA Care Health Plan (Los Angeles, CA)
- Supervisor, Utilization Management RN Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full Time ... required to achieve that purpose. Job Summary The Supervisor of Utilization Management ( UM ) RN is responsible for executing the day-to-day operations of the UM… more
- LA Care Health Plan (Los Angeles, CA)
- …for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, ... Utilization Management Admissions Liaison RN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full… more
- Alameda Health System (Oakland, CA)
- …a Registered Nurse in the State of California. Preferred Licenses/Certifications: UM / CM certifications Alameda Health System is an equal opportunity employer ... direction of utilization practices; assists physicians and hospital personnel in understanding UM matters. + Perform all other duties as assigned. + Prepares cost… more
- Centene Corporation (Sacramento, CA)
- …the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, ... Purpose:** Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises… more
- Datavant (Sacramento, CA)
- …recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed ... Practical Nurse or Registered Nurse well versed in...denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. **You will:** +… more
- Molina Healthcare (Los Angeles, CA)
- California residents preferred.** **EMERGENCY ROOM ADMISSIONS REVIEW NURSE ** **_3-12 NIGHT SHIFT 7:30PM - 08:30AM PACIFIC HOURS NON EXEMPT, 3 days a week will ... hours as posted._** **JOB DESCRIPTION** **Job Summary** Provides support for clinical member services review assessment processes. Responsible for verifying that… more
- Sutter Health (Burlingame, CA)
- …+ RN-Registered Nurse of California + CCM- Preferred + LCSW-Licensed Clinical Social Worker (Preferred) **PREFERRED EXPERIENCE AS TYPICALLY ACQUIRED IN:** + 8 ... and guidelines. Has frequent contact with the Administrative Team, Nurse Executives and Directors, Risk Management & Ethics staff,...and social needs. + 8 years experience in coordinating UM Committees/and or Clinical Review teams. +… more
- Molina Healthcare (CA)
- …Pacific business hours.** JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that ... services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes… more
- Cedars-Sinai (Beverly Hills, CA)
- …care. Use Milliman and Interqual guidelines as necessary. + Collaborates with clinical teams and practices to ensure synchronization of sub-areas' operations to ... day (preferably on day of admission). + Submits necessary clinical information to the health plan using the accepted...are transitioning to the Skilled Nursing Facilities, refers to nurse practitioner and case manager assigned to the SNF's… more
- Molina Healthcare (San Bernardino, CA)
- …at the most effective setting. *Evaluates effectiveness of utilization management ( UM ) practices - actively monitoring for over and under-utilization. * Educates ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more
- Elevance Health (Los Angeles, CA)
- …outpatient precertification, prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer. + Responsible for the ... identification and data entry of referral requests into the UM system in accordance with the plan certificate. + Responds to telephone and written inquiries from… more