Utilization review nurse jobs in Costa Mesa, CA

Utilization Management Coordinator External Description: Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time. By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community. Position Summary: The Utilization Management (UM) Clerk will assist in the clerical support to the UM department staff (i.e. incoming/outgoing mail, data entry, filing, etc.) General Duties/Responsibilities: (May include but are not limited to) · Responsible for processing incoming and outgoing mail for the UM Department. · Maintains inventory of office supplies at a level necessary for proper functioning of the department. · Performs clerical duties deemed necessary to ensure smooth functioning of the department. · Performs data entry as requested. · Assist Inpatient team by entering Face Sheets and faxes. · Data integrity testing for new projects or project enhancement · Ensures delegated IPA/MGs provide CCHP with discharge dates, authorized days and discharge disposition on members assigned to delegated IPA/MG by faxing requests for information, tracking receipt of information and forwards information to Inpatient Team. · Call hospitals to obtain billing charges and maintain billing log. · Meets specific deadlines (responds to various workload by assigning task priorities according to department policies, standards, and needs). · Maintain Department miscellaneous filing in an organized fashion as well as create files as needed. · Recognizes work-related problems and contributes to solutions. · Maintains confidentiality of information between and among health care professionals. · Other duties as assigned by UM Management. Minimum Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Minimum Experience: a. Minimum of one-year in clerical support. 2. Education/Licensure: a. High school diploma or general education degree (GED) b. At least six months related experience and/or training; or equivalent combination of education and experience. 3. Other: a. Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. b. Mathematical Skills: Ability to add and subtract two digit numbers and to multiply and divide with 10's and 100's. Ability to perform these operations using units of American money and weight measurement, volume, and distance. c. Typing speed 45 wpm and proficient use of 10-key calculator. d. Computer Skills: Microsoft Office. Knowledge of computer programs and applications required. e. Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. i. Excellent communication skills, oral and written. 4. Work Environment a. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. i. The noise level in the work environment is usually moderate. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. 2. The employee is frequently required to walk; stand; reach with hands and arms. 3. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. 4. The employee must occasionally lift and/or move up to 20 pounds. 5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran. If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact ******************. City: Orange State: California Location City: Orange Schedule: Full Time Location State: California Community / Marketing Title: Utilization Management Coordinator Company Profile: Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time. By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community. EEO Employer Verbiage: On August 17, 2021, Alignment implemented a policy requiring all new hires to receive the COVID-19 vaccine. Proof of vaccination will be required as a condition of employment subject to applicable laws concerning exemptions/accommodations. This policy is part of Alignment's ongoing efforts to ensure the safety and well-being of our staff and community, and to support public health efforts. Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran. If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact ******************.

Benefits: 401(k) Competitive salary Dental insurance Health insurance Paid time off Signing bonus Training & development Vision insurance Outpatient Case Management West Los Angeles VAMC 11301 Wilshire Blvd Los Angeles, CA. 90073 There are five new RN vacancies at the West Los Angeles VA Medical Center. Service Line | Unit | Position Title | Tour | Qualified Contractor | Vendor HOSPITAL OPERATIONS | INPATIENT | RN | 0630-1500 | Vacant | Open HOSPITAL OPERATIONS | INPATIENT | RN | 0630-1500 | Vacant | Open HOSPITAL OPERATIONS | INPATIENT | RN | 0630-1500 | Vacant | Open HOSPITAL OPERATIONS | OUTPATIENT | RN | 0730-1600 | Vacant | Open HOSPITAL OPERATIONS | OUTPATIENT | RN | 0730-1600 | Vacant | Open Benefits/Perks Competitive Compensation Great Work Environment Career Advancement Opportunities Job SummaryWe are seeking a Utilization Management Nurse to join our team! As a Utilization Management Nurse on the team, you will be responsible for reviewing patient files and treatment methods with an eye for efficiency and effectiveness. Your role will be to ensure we are running at optimal efficiency, and that all patients under our care are receiving the necessary treatments and procedures. The ideal candidate has deep experience in a similar medical setting, has a bachelor's or higher in Nursing, and has a certification in either Case Management or Utilization Management. Responsibilities Review patient files and treatment information for efficiency Monitor the activity of staff to ensure effective patient treatment Advocate for quality patient care to prevent complications Review discharge information for outgoing patients Work closely with clinical staff to provide excellent patient care Prepare reports on patient management and cost assessments Dimensions of Nursing Practice PRACTICE: Knowledge of professional nursing practice and the ability to apply the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) with close supervision.Expectations:1. Completes orientation according to expected standards. 2. Works with close supervision, is responsible and accountable for individual nursing practice and seeks direction from others as needed. 3. Manages workload as assigned, organizes, and completes own assignments in an efficient and appropriate manner. 4. Participates in the development, implementation, and evaluation of interdisciplinary care.5. For Inpatient RNs, performs unit based inpatient case management duties, with the ability to perform RN case management assessments, discharge planning, formulating safe plans of care and anticipating patient care needs. VETERAN/PATIENT DRIVEN CARE: Knowledge of Veteran/patient driven care, patient experience, satisfaction, and safety.Expectations:1. Establishes a therapeutic relationship, allowing the patient to attain, maintain or regain optimal function through assessment and treatment. 2. Engages patients, families, and other caregivers to incorporate knowledge, values, and beliefs into care planning without judgement or discrimination. 3. Knowledgeable of ethical issues related to professional nursing practice and follow established policies of the practice setting, VA, and ANA Code of Ethics for Nurses. 4. Aware of high reliability principles to deliver consistent care and improve patient outcomes. LEADERSHIP: Communicates, collaborates, and utilizes leadership principles to perform as an effective member of the interprofessional team.Expectations:1. Demonstrates positive, effective communication skills and professional behaviors that promote cooperation and teamwork with internal and external customers. PROFESSIONAL DEVELOPMENT: Incorporates educational resources/opportunities and self-evaluation for professional growth.Expectations:1. Participates in unit based educational activities and continuing education requirements. 2. Responsible for maintaining competency to continue personal and professional growth. EVIDENCE-BASED PRACTICE/RESEARCH: Awareness of evidence-based practice/research to improve quality of care and resource utilization.Expectations:1. Applies evidence-based practice/research to patient care. 2. Participates in unit-based activities to improve and deliver cost effective patient care. 3. Demonstrates knowledge of specific unit level performance improvement activities. 4. Incorporates patient preferences into shared care delivery decisions. Customer Services Requirements: The incumbent meets the needs of the Veteran and as appropriate the Veteran's family, caregiver and/or significant other, the Veteran's representative, visitors to VA facilities, all VA staff and other customers while supporting VA missions. The incumbent consistently communicates and treats the Veteran and as appropriate the Veteran's family, caregiver and/or significant other, the Veteran representatives, visitors to VA facilities, all VA staff, and other customers in a courteous, tactful, and respectful manner. The incumbent provides the Veteran's family, caregiver and/or significant other, the Veteran's representative, visitors to VA facilities, all VA staff, and other customers with consistent information according to establish policies and procedures. The incumbent handles conflict and problems in dealing with any consumer group appropriately and in a constructive manner. Age, Development, and Cultural Needs of Patients Requirement: The primary age of Veterans treated is in their middle years (ages 40 to 50) or at the geriatric level (ages 60 or older). There are occasionally younger patients between the ages of 25 to 40 years of age that require care. The position requires the incumbent to possess or develop an understanding of the particular needs of these types of patients. Sensitivity to the special needs of all patients in respect to age, developmental requirements, and culturally related factors must be consistently achieved. Computer Security Requirement: The incumbent protects printed and electronic files containing sensitive data in accordance with the provisions of the Privacy Act of 1974 and other applicable laws, Federal regulations, VA statutes and policy, and VHA policy. The incumbent protects the data from unauthorized release or from loss, alteration, or unauthorized deletion. Follows applicable regulations and instructions regarding access to computerized files, release of access codes, etc., as set out in the computer access agreement that the incumbent signs. Reports all known information security incidents or violations to the supervisor and/or the Information Security Officer immediately. Reports all known privacy incidents or violations to the Privacy Officer immediately. Compliance is measured by supervisory observation and periodic random monitoring by the Information Security Officer or Office of Information Technology staff. Major violations such as loss of or unauthorized release, alteration, or deletion of sensitive data are unacceptable. Other Significant Information: This position potentially requires flexibility in schedule and assignments. For RN Inpatient Case Management staff, there may be rotation to 0830-1700 from the initial 0630-1500 (Monday - Friday) Qualifications: BSN and/or MSN preferred. Minimum of 5 years of successful nursing practice, encompassing education, administration, leadership, and Quality Management Performance Improvement (QM/PI) experience preferred. Basic computer literacy proficiency with the use of Microsoft Office programs or comparable word processing, spreadsheet and graphic software and the ability to learn new programs specific to the VA preferred. Ability to work variable and flexible tours to meet program demands. Demonstrated ability to accurately implement policies, regulations, standards of care and standards of practice preferred. Demonstrated ability to review patient clinical records. Proven ability to facilitate group problem solving preferred. Proven ability to utilize sound judgment in making patient transfer decisions preferred. Ability to lead and effectively direct staff within program unit/team/group preferred. Excellent organizational, communication, writing, and time management skills preferred. Excellent interpersonal skills and the ability to work independently as well as collaboratively with multiple service lines and disciplines preferred. Compensation: $60.00 - $75.00 per hour PROVIDING QUALITY STAFFING AND CONSULTING SINCE 2011 Based out of San Antonio, Tex as, our minority women-owned company specializes in all staffing and consulting needs. Whether you're trying to hire a pharmacist, a respiratory therapist, or skilled and non-skilled laborer, we will staff your company with the best candidate. We bring extensive experience and professionalism and we will personalize our assistance to your needs and concerns. Most of our contracts are with the Army and Air Force as Sub-Contractors. Our staff has a quick turn around and have been able to fill positions within 48 hours with short notice, we have filled hard to fill locations and jobs, and managed over 16 contracts with over 70 employees at a time. Managed call-ins at 24/7 hospitals and ensured shifts were filled, and managed PRNs with notice of less than 24 hours. Also, provided temp laborers for next day jobs. Our consulting division provides contracting assistance, program managing, application assistance, certification assistance and proposal writing. We are very knowledgeable in a variety of areas and are eager to assist your company's prosperity.

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Must be located in the state of California Schedule: 9:30am-6:00pm PST, ability to work weekends if necessary. New Grads are encouraged to apply! The Nurse Reviewer I will be responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. * Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. * Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. * Partners with more senior colleagues to complete non-routine reviews. * Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. How you will make an impact: * Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review. * Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. * Notifies ordering physician or rendering service provider office of the preauthorization determination decision. * Follows-up to obtain additional clinical information. * Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics. Minimum Requirements: * AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. * Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities, and Experiences: * Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred. * BA/BS degree preferred. * Previous utilization and/or quality management and/or call center experience preferred. * Knowledge in Microsoft office. For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $31.54/hr - $56.77/hr Locations: California In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

About Us All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and passion for making a difference. We support a culture focused on teamwork, support, and inclusion. We offer a flexible work environment and schedules with work from home options. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. Additional employee paid coverage options available. We also offer paid holidays, birthday off, and unlimited PTO as well as a 401k plan. Job purpose As a Concurrent Review Nurse, you will be responsible for coordinating and overseeing the care of patients receiving inpatient medical services. Working closely with healthcare providers, patients, and their families, you will ensure that patients receive comprehensive and coordinated care, promote continuity of care, and optimize patient outcomes. Duties and responsibilities The role of the concurrent review nurse to provide patient advocacy through appropriate utilization of services. Manage inpatient cases to ensure that medical care is medically necessary by conducting concurrent review and retrospective review for appropriateness of admission, level of care and determines length of stay. Overall planner of utilization efforts to effectively manage care from admission to discharge. Communicates with the facilities to get clinical information. Communicates with the facilities to get coordinate discharge planning for the member. Conduct case review based on criteria (InterQual or MCG) and makes a determination based on turnaround times established by the company. Comply with UM policies and procedures. Annual review of UM policies. Maintains Interrater Reliability Rate at least 95% or above. Act as clinical resources to all departments. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization or appropriate services to our patients. Attend to provider and interdepartmental calls in accordance with exceptional customer service. Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers and members. Always maintain strict confidentiality. Other duties as needed. Qualifications Current licensure or certification as a Registered Nurse (RN), Licensed Vocational Nurse. depending on the jurisdiction and requirements. CM and/or UM training and/or certification. Strong Knowledge of Medicare, Commercial and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working knowledge of common diagnoses, procedures and diagnostic codes. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements models such as DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around inpatient, Observation and Outpatient levels of patient management. A high degree of self-directed organizational skills, ability to set priorities, manage multiple demands and the ability to work independently and as a part of a multidisciplinary team. Able to work in a variety of computer programs, including InterQual, Ezcap, and Microsoft. Five years+ clinical experience. Prefer two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended. Commitment to patient-centered care, cultural competence, and ethical practice. Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe Detail oriented and highly organized. Strong ability in problem-solving Ability to manage self-manage, strong time management skills. Ability to work in an extremely confidential environment. Strong written and verbal communication skills Salary Range: $70,000 - $95,000 annually (LVN) depending on experience $85,000 - 120,000 annually (RN) depending on experience

The PACE Utilization Review Specialist - RN oversees clinical utilization management for participants enrolled in the Program for All-Inclusive Care for the Elderly. The position ensures that services are medically appropriate, cost-effective, and coordinated. This role works closely with the PACE Medical Director and interdisciplinary team to review clinical cases, manage utilization policies, and ensure regulatory compliance. Essential Duties and Responsibilities * Conduct concurrent and retrospective utilization reviews for acute, post-acute, and outpatient services. * Review clinical documentation and determine appropriate levels of care based on evidence-based criteria. * Manage inpatient and post-acute length of stay and coordinate timely discharge planning. * Review, develop, and implement utilization management policies and workflows. * Prepare and present clinical case summaries and recommendations to internal leadership. * Serve as a resource for primary care providers and care managers on utilization and authorization requirements. * Ensure appropriate service authorization for hospitalizations, referrals, and specialty services. * Communicate with providers, payers, and internal teams regarding claim adjudication and payment status. * Identify high-risk participants and coordinate with clinical leadership on care strategies. * Track and report utilization metrics and trends to support program improvement. * Oversee denial management processes and provider appeal reviews. * Document all utilization management activities in the electronic medical record. * Participate in interdisciplinary team meetings and care planning sessions. * Support staff education and training on utilization management policies and standards. Minimum Qualifications * Graduate of an accredited school of nursing with a current unencumbered Registered Nurse license in the State of California. * Current BLS certification from the American Heart Association. * Valid California driver's license and acceptable driving record. * Minimum three years of managed care experience, including one year in utilization management, case management, or care coordination. * Minimum one year of experience working with the frail or elderly population. * Strong analytical skills with the ability to evaluate clinical documentation and apply evidence-based criteria. * Knowledge of State and Federal healthcare regulations, quality standards, and utilization review principles and guidelines such as Medicare, Medicaid and MCG/InterQual. * Proficient in Microsoft Office, including advanced Excel skills. * Excellent communication skills, both written and verbal. * Demonstrated ability to work collaboratively across multidisciplinary teams. Preferred Qualifications * Bachelor of Science in Nursing (BSN) strongly preferred. * Certified Case Manager (CCM) or Certified Professional in Healthcare Management (CPHM) preferred. Physical Demands and Work Environment * Requires standing, walking, occasional pushing, pulling, and lifting. * Ability to lift up to 30 pounds; assistance required for heavier loads. * Manual dexterity and visual/hearing acuity required for clinical assessment and documentation. * Exposure to infectious materials and biohazards common in healthcare settings. * Must be able to communicate with participants, caregivers, and team members, including those with cognitive or physical limitations. * Moderate stress related to deadlines, caseload volume, and patient conditions. Direct Reports PACE Medical Director

EXAM NUMBER Y5125L TYPE OF RECRUITMENT We welcome applications from anyone! FILLING DATE The application filing period will begin on May 22, 2025, at 9:00 a.m. (PT) - Continuous. We will keep accepting applications until the position is filled. The application window may close unexpectedly once we have enough qualified candidates. Why Join the LA County Department of Health Services? The Los Angeles County Department of Health Services (DHS) is more than just a healthcare provider - we're a cornerstone of our community's health. As the second largest municipal health system in the nation, DHS operates an integrated network of 25 health centers and four hospitals, alongside an expanded network of community partner clinics. Every year, we deliver compassionate, life-saving care to over 600,000 unique patients across LA County. With more than 23,000 dedicated staff members and an annual budget exceeding $6.9 billion, DHS is dedicated to transforming healthcare and creating lasting change in our community. For additional information regarding DHS please visit www. dhs.lacounty.gov Check Out Our Outstanding Benefits! We offer one of the strongest public-sector benefits packages in the country. Join us and discover a rich selection of health care options, robust retirement plans and the flexibility to work, relax and rejuvenate as you reach your fullest personal and professional potential. Click here to see comprehensive information regarding County employee benefits. DHS is seeking dedicated Utilization Review Nurse Supervisors to join our team. Whether you're working in community clinics or hospitals, this is your opportunity to grow your career while serving diverse communities across LA County. Definition: Provides technical and administrative direction to staff performing reviews of patients' medical charts to ascertain the medical necessity for services and the appropriateness of the level of care.What You'll Be Doing: * Plans, directs, assigns, and evaluates the work of subordinates engaged in utilization review activities. * Plans, develops, and implements procedures to fulfill the requirements and guidelines for an effective and timely utilization review system. * Confers with physicians, administrative personnel, and other disciplines in the hospital to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures. * Determines need for and conducts in-service training to improve quality of admission and continued stay reviews, and to disseminate information concerning new or revised procedures. * Works with Professional Standards Review Organization representative to orient new staff to Federal laws and regulations pertaining to Medicare and Medi-Cal reimbursement. * Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for the referral of unusual questionable cases, on referred cases for reconsideration, and to obtain authorization for the issuance of denial letters. * Reviews, retrospectively, utilization review records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information. * Develops procedures for the compilation of information from medical charts concerning particular diagnoses, problems, procedures, or practitioner categories as directed for medical care evaluation studies. * Prepares and analyzes reports on number and status of reviews, physician advisor referrals, and type of physician advisor determinations to determine if improvement in procedures or additional staff training is needed, and to make recommendations on potential areas for medical care evaluation studies. * Attends Utilization Review Committee meetings to inform the committee of new or revised utilization review requirements, the impact of the requirements, and procedures to be implemented for compliance, as needed. * As a unit supervisor at the LA General Medical Center: * Has immediate responsibility for organizing, assigning, and evaluating the work of at least seven Utilization Review Nurses. * Acts as a technical resource person to subordinate staff concerning Federal regulations pertaining to Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards. * Participates in the formulation of and changes in utilization review procedures by assessing the effectiveness of the review system and providing information on the policies and procedures within the assigned medical areas. * Provides input for the in-service training program by identifying areas of deficiency in staff knowledge or experience. * Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for follow up on referrals. * Reviews, retrospectively, Utilization Review Records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information. * Compiles data on number and status of reviews, physician advisor referrals, and type of physician advisor determinations. * Maintains effective working relationships with unit physicians to facilitate the execution of the utilization review system. * Participates in the work performed by subordinates. SELECTION REQUIREMENTS: OPTION I: One year of experience performing the duties of a Utilization Review Nurse* or Medical Service Coordinator, CCS. * OR- OPTION II: Two (2) years of experience as a registered nurse, of which one year must be in the treatment of chronic and short- term medical and surgical inpatient problems, AND one (1) year of experience in the first-level supervision* of registered nurses and other nursing staff. LICENSE REQUIREMENT INFORMATION: * A current, active license to practice as a Registered Nurse issued by the California Board of Registered Nursing. * A current Basic Life Support (BLS) for Healthcare Providers (CPR & AED) Program certification issued by the American Heart Association. Applicants must ensure the Certificates and Licenses Section of the application is completed. Provide the title(s) of your required certification(s) and/or license(s), the number(s), date(s) of issue, date(s) of expiration, and the name(s) of the issuing agency for the required certification(s) and license(s) specified above. Required certificates and licenses has to be active and unrestricted, or your application will not be accepted. Applicants must attach a legible copy/image of required and/or desired certifications and licenses to their application at the time of filing, or email the document/s to the exam analyst to aharraway@dhs.lacounty,gov within seven (7) calendar days from the application date. Applications submitted without the required certificates and/or licenses will be rejected. Applicants claiming experience in a state other than California have to provide their Registered Nurse license number from that state on the application at the time of filing. Out-of-State experience provided on the application without the required license number will not be considered. PHYSICAL CLASS: Physical Class II - Light: This class includes administrative and clerical positions requiring light physical effort that may include occasional light lifting to a 10-pound limit and some bending, stooping, or squatting. Considerable ambulation may be involved. SPECIAL REQUIREMENTS INFORMATION: * An Utilization Review Nurse is an RN that has Case Management experience whose primary charge is to ensure that the care provided to patients are appropriate and covered by the insurance payer. They are responsible for ensuring that patient services are cost-effective, and their stay is at the appropriate level of care and length of stay. In the County of Los Angeles, a Medical Service Coordinator, CCS determines medical eligibility of children referred to California Children Services and approves and coordinates treatment services for children accepted under the program. * For this examination, supervision MUST include all the following: planning, assigning, reviewing work of staff and formally evaluating employee performance. To receive credit for your education, include a copy of your official diploma, official transcript, or letter/certificate from an accredited institution with your application at the time of filing or within seven (7) calendar days of filing your application. The document should show the date the degree was conferred and be in English; if it is in a foreign language, it must be translated and evaluated for equivalency to U.S. standards. For more information on our standards for educational documents, please visit:***************************************************************** PDF reader)and ************************************************************************************* PDF reader). Please submit documentation to ************************** and indicate your name, the exam name, and the exam number. We do not accept password-protected documents. Ensure documents are unlocked before attaching to your application or sending to the exam analyst. DESIRABLE QUALIFICATIONS: Additional credit will be given to applicants who possess the following desirable qualifications in excess of the Selection Requirements: * A Bachelor's Degree in Nursing or higher from an accredited institution. * Additional experience of first-level supervision* of registered nurses and other nursing staff in excess of the selection requirements. EXAMINATION CONTENT: This exam will consist of an evaluation of experience based upon application information, supplemental questionnaire, and desirable qualifications weighted 100%. CANDIDATES ACHIEVING A PASSING SCORE OF 70% OR HIGHER WILL BE ADDED TO THE ELIGIBLE REGISTER. ELIGIBILITY INFORMATION: We process applications as we receive them. If you pass the assessment, we will place you on a list for 12 months. The hiring managers within DHS will use this list to fill vacancies as they become available. Applicants who are successful in this examination and are added to the eligible register may not apply for and compete in this examination for twelve (12) months following the date of being placed on the eligible register. Applications received before expiration from the eligible register will be rejected. Applicants who have applied and did not meet the Requirements at the time of filing may reapply 30 days from their latest application date. VACANCY INFORMATION: The eligible register resulting from this examination will be used to fill vacancies throughout Los Angeles County as they occur. AVAILABLE SHIFTS: You may be required to work evenings, nights, weekends, and holidays, depending on operational needs. APPLICATION AND FILING INFORMATION: We only accept applications filed online. Applications submitted by U.S. mail, fax, or in person are not accepted. Apply online by clicking on the "Apply" green button at the top right of this posting. This website can also be used to get application status updates. New email addresses need to be verified. This only needs to be done once per email address and can be done at any time by logging in to govermentjobs.com and following the prompts. This is to enhance the security of the online application and to prevent incorrectly entered email addresses. Please fill out the application completely. Provide relevant job experience including employer's name and address, job title, beginning and ending dates, number of hours worked per week, and description of work performed. We may verify information included in the application at any point during the examination and hiring process, including after an appointment has been made. Falsification of information could result in refusal of application or rescission of appointment. Copying verbiage from the Requirements or class specification as your work experience will not be sufficient to demonstrate meeting the requirements. Doing so may result in an incomplete application and may lead to disqualification. We will send notifications to the email address provided on the application, so it is important that you provide a valid email address. If you choose to unsubscribe or opt out from receiving our emails, it is possible to view notices by logging into governmentjobs.com and checking the profile inbox. It is every applicant's responsibility to take steps to view correspondence, and we will not consider claims for missing notices to be a valid reason for re-scheduling an exam part. Register the below domains as approved senders to prevent email notifications from being filtered as spam/junk mail. ************************** noreply@governmentjobs.com *********************** Social Security Number: Federal law requires that all employed persons have a Social Security Number, so include yours when applying. Computer and Internet Access at Public Libraries: For candidates who may not have regular access to a computer or the internet, applications can be completed on computers at public libraries throughout Los Angeles County. No Sharing of User ID, E-mail and Password: All applicants must file their application using their own user ID and password. Using a family member or friend's user ID and password may erase a candidate's original application record. Anti-Racism, Diversity, and Inclusion (ARDI): The County of Los Angeles recognizes and affirms that all people are created equal and are entitled to all rights afforded by the Constitution of the United States. The Department of Human Resources is committed to promoting Anti-racism, Diversity, and Inclusion efforts to address the inequalities and disparities amongst races. We support the ARDI Strategic Plan and its goals by improving equality, diversity, and inclusion in recruitment, selection, and employment practices. * For any inquiries about the position or assistance with the application process, please contact Alvonte Harraway at **************************. Alvonte is here to guide you every step of the way. * Department Contact Phone: ************** * Teletype Phone: ************** * California Relay Services Phone: ************** * For Accommodation requests, please contact our Accommodation Coordinator, via ************** * Please reference Exam Number: Y5125L in all communications during the application process.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth. Who Are We? Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values. Why Join Us? We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. Job Summary The Utilization Review Nurse will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings. Functions & Job Responsibilities * May provide any of the following in support of medical claims reviews, appeal reviews, and utilization review practices. * Completes medical necessity reviews for requested services using clinical judgment and refers cases to Medical Directors when needed * Educate providers on utilization and medical management processes * Provide clinical knowledge and act as a clinical resource to non-clinical team staff * Enter and maintain pertinent clinical information in various medical management systems * Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. * Conducts research necessary to make thorough/accurate basis for each determination made * Work on special projects related to utilization management as needed * Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations * Audit case reviews to ensure compliance with utilization management policies and procedures * Assist with the development of utilization management workflows, policies, and procedures * Participates in all required training * Assist with training for new hires and continued development of existing staff * Serve as a back up to direct manager as needed * Participate in daily census review process and productivity review for staff. * Other duties as assigned

Formulary Strategy & Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: Review prescribing trends and propose cost-saving alternatives. Maintain evidence-based formularies across multiple payers. Conduct retrospective DUR and prepare stakeholder reports. Qualifications: PharmD with managed care, DUR, or pharmacy benefit experience. Strong Excel/data analytics background preferred. Understanding of clinical guidelines and P&T processes. Why Join Us? Join a top-tier managed care team Hybrid flexibility Strategic and data-driven focus

Cordoba Corporation is a leading engineering and program management firm based in California. We are seeking Senior Field Utility Coordinator to support utility coordination efforts for major infrastructure projects across the Energy, Transportation, and Water sectors. This role focuses on hands-on utility coordination, ensuring timely relocation and conflict resolution for wet and dry utilities on transit, municipal, highway, and airport projects. The ideal candidate will have strong experience in subsurface utility engineering (SUE), relocation strategies, and regulatory compliance, with proven ability to coordinate with multiple agencies and utility owners statewide. This is a unique opportunity to contribute to the growth of Cordoba's statewide Utility Coordination Program while playing a pivotal role in delivering complex infrastructure projects. Responsibilities Perform utility clearance activities, including desktop investigations, Subsurface Utility Engineering (SUE) investigations, potholing, and conflict analysis. Review engineering design plans and prepare utility conflict matrices, schedules, relocation agreements, and supporting documentation. Maintain and update GIS-based utility data systems, ensuring accuracy and usability across project teams. Identify potential relocations, easements, and prepare utility construction permits, Notices to Owners (NTO), and Utility Agreements (UA). Apply ASCE 38-22 standards and industry best practices in utility research, data management, and conflict resolution. Act as primary point of contact with public and private utility owners (water, wastewater, gas, electric, telecom, storm drain). Facilitate coordination meetings and provide clear communication through reports, maps, as-builts, and design documentation. Coordinate with Caltrans, municipalities, and regional authorities to ensure compliance with applicable state, local, and federal regulations. Support the development and implementation of procedures that improve efficiency and consistency in utility coordination. Provide guidance and mentorship to junior utility coordination staff and field personnel. Collaborate with colleagues across the Energy, Transportation, and Water sectors to ensure integrated project delivery. Qualifications Bachelor's degree in Civil Engineering, Construction Management, or related field (or equivalent experience) 5+ years of professional experience in utility coordination, relocation, and subsurface investigations required Knowledge of ASCE 38-22, relocation strategies, and regulatory requirements required Utility coordinator experience with wet and dry utility systems and right-of-way considerations required Familiarity with Caltrans procedures and alternative delivery methods (design-build) Effective communication and negotiation skills with the ability to collaborate with utility clients and customers, engineers, inspectors, and construction crews OSHA 20 training preferred Experience with GIS-based utility databases and MicroStation/AutoCAD for plotting utilities in 2D/3D preferred Proficient in the MS Office suite including Word, Excel, PowerPoint, and Outlook Ability to work primarily in the field and occasionally in office, including travel to various project sites Pay Range: $100,000 - $130,000 per year Work Location: 4-5 days per week in the field and office in the Southern California area Travel: 80% travel to field sites within the Southern California area Visa Sponsorship: Legal authorization to work in the U.S.A. on a full-time basis without sponsorship Physical Requirements: Ability to pass a pre-authorized physical including a drug-screening and background check Our Company Cordoba Corporation, Making a Difference Cordoba Corporation is a nationally recognized civil engineering, construction management, program management, and planning firm. Our expertise spans diverse sectors, including education and facilities, transportation, water, and energy. Collaborating closely with our clients, we have successfully delivered complex and high-impact infrastructure projects across California. National Recognition - Cordoba's efforts have garnered national acclaim. Engineering News-Record (ENR) has consistently ranked us as a “top 100 construction management firm” and a “top 50 program management firm.” Additionally, ENR recognized Cordoba as a “top 100 design firm” in California in 2018. Our business model emphasizes efficiency, fostering a dynamic work environment. We approach projects with multifaceted strategies, ensuring successful outcomes. Statewide Presence - With headquarters in Los Angeles, Cordoba maintains a strong statewide presence. Our offices extend to San Francisco, Sacramento, San Ramon, Chatsworth, Santa Ana, Ontario, and San Diego. Enhancing Employee Well-Being Benefits and Perks: We offer multiple medical and dental insurance plans, as well as vision insurance. Plans are subsidized for both employees and dependents with coverage effective the first month after hire. Additionally, Cordoba provides employees with paid AD&D and life insurance, a 401k with an industry leading employer match, generous vacation and sick leave accruals, 9 paid holidays, and other forms of paid time off. We also offer flexible spending accounts (FSA's) including medical care reimbursement, dependent care reimbursement, and commuter benefit plans. Employees are also eligible for our employee assistance program and well-being benefits that include stress management, nutrition, and financial well-being. Cordoba Corporation provides equal employment opportunities, promoting diversity and inclusion. We welcome applicants regardless of race, color, religion, sex, national origin, age, disability, or genetics. Harassment-Free Workplace: We strictly prohibit workplace harassment based on any factor, including race, gender, sexual orientation, or disability. Cordoba is committed to fostering a healthy and happy lifestyle for our employees, both within and beyond the workplace. For inquiries or accommodations, please contact our HR Department at: **************. Join Cordoba Corporation and be part of shaping California's future!

Cordoba Corporation is a leading engineering and program management firm based in California. We are seeking Senior Field Utility Coordinator to support utility coordination efforts for major infrastructure projects across the Energy, Transportation, and Water sectors. This role focuses on hands-on utility coordination, ensuring timely relocation and conflict resolution for wet and dry utilities on transit, municipal, highway, and airport projects. The ideal candidate will have strong experience in subsurface utility engineering (SUE), relocation strategies, and regulatory compliance, with proven ability to coordinate with multiple agencies and utility owners statewide. This is a unique opportunity to contribute to the growth of Cordoba's statewide Utility Coordination Program while playing a pivotal role in delivering complex infrastructure projects. Responsibilities Perform utility clearance activities, including desktop investigations, Subsurface Utility Engineering (SUE) investigations, potholing, and conflict analysis. Review engineering design plans and prepare utility conflict matrices, schedules, relocation agreements, and supporting documentation. Maintain and update GIS-based utility data systems, ensuring accuracy and usability across project teams. Identify potential relocations, easements, and prepare utility construction permits, Notices to Owners (NTO), and Utility Agreements (UA). Apply ASCE 38-22 standards and industry best practices in utility research, data management, and conflict resolution. Act as primary point of contact with public and private utility owners (water, wastewater, gas, electric, telecom, storm drain). Facilitate coordination meetings and provide clear communication through reports, maps, as-builts, and design documentation. Coordinate with Caltrans, municipalities, and regional authorities to ensure compliance with applicable state, local, and federal regulations. Support the development and implementation of procedures that improve efficiency and consistency in utility coordination. Provide guidance and mentorship to junior utility coordination staff and field personnel. Collaborate with colleagues across the Energy, Transportation, and Water sectors to ensure integrated project delivery. Qualifications Bachelor's degree in Civil Engineering, Construction Management, or related field (or equivalent experience) 5+ years of professional experience in utility coordination, relocation, and subsurface investigations required Knowledge of ASCE 38-22, relocation strategies, and regulatory requirements required Utility coordinator experience with wet and dry utility systems and right-of-way considerations required Familiarity with Caltrans procedures and alternative delivery methods (design-build) Effective communication and negotiation skills with the ability to collaborate with utility clients and customers, engineers, inspectors, and construction crews OSHA 20 training preferred Experience with GIS-based utility databases and MicroStation/AutoCAD for plotting utilities in 2D/3D preferred Proficient in the MS Office suite including Word, Excel, PowerPoint, and Outlook Ability to work primarily in the field and occasionally in office, including travel to various project sites Pay Range: $100,000 - $130,000 per year Work Location: 4-5 days per week in the field and office in the Southern California area Travel: 80% travel to field sites within the Southern California area Visa Sponsorship: Legal authorization to work in the U.S.A. on a full-time basis without sponsorship Physical Requirements: Ability to pass a pre-authorized physical including a drug-screening and background check Our Company Cordoba Corporation, Making a Difference Cordoba Corporation is a nationally recognized civil engineering, construction management, program management, and planning firm. Our expertise spans diverse sectors, including education and facilities, transportation, water, and energy. Collaborating closely with our clients, we have successfully delivered complex and high-impact infrastructure projects across California. National Recognition - Cordoba's efforts have garnered national acclaim. Engineering News-Record (ENR) has consistently ranked us as a “top 100 construction management firm” and a “top 50 program management firm.” Additionally, ENR recognized Cordoba as a “top 100 design firm” in California in 2018. Our business model emphasizes efficiency, fostering a dynamic work environment. We approach projects with multifaceted strategies, ensuring successful outcomes. Statewide Presence - With headquarters in Los Angeles, Cordoba maintains a strong statewide presence. Our offices extend to San Francisco, Sacramento, San Ramon, Chatsworth, Santa Ana, Ontario, and San Diego. Enhancing Employee Well-Being Benefits and Perks: We offer multiple medical and dental insurance plans, as well as vision insurance. Plans are subsidized for both employees and dependents with coverage effective the first month after hire. Additionally, Cordoba provides employees with paid AD&D and life insurance, a 401k with an industry leading employer match, generous vacation and sick leave accruals, 9 paid holidays, and other forms of paid time off. We also offer flexible spending accounts (FSA's) including medical care reimbursement, dependent care reimbursement, and commuter benefit plans. Employees are also eligible for our employee assistance program and well-being benefits that include stress management, nutrition, and financial well-being. Cordoba Corporation provides equal employment opportunities, promoting diversity and inclusion. We welcome applicants regardless of race, color, religion, sex, national origin, age, disability, or genetics. Harassment-Free Workplace: We strictly prohibit workplace harassment based on any factor, including race, gender, sexual orientation, or disability. Cordoba is committed to fostering a healthy and happy lifestyle for our employees, both within and beyond the workplace. For inquiries or accommodations, please contact our HR Department at: **************. Join Cordoba Corporation and be part of shaping California's future!

Nurse Manager - Case Management, Float Pool, & Staffing Administration - (10033192) Description Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope's growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago, and Phoenix. our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today. City of Hope Lennar Foundation Cancer Center seeks a capable Nurse Manager to ensure efficient operations and workflows for the hospital, patient placement, and nursing policies needed to bring the hospital online. Once the hospital is open, this position will transform, and the Nurse Manager will be responsible for overseeing the house supervisors, patient safety, and daily hospital operations building and enhancing relationships through customer relations and appropriate professional involvement. The manager will work closely with multidisciplinary teams to develop services and ensure quality. As a successful candidate, you will:Assure satisfaction of patients, physicians and other customers with care and services that are delivered. Develop and foster collaborative relationships with other departments to support safe and high-quality patient care and services. Promote the implementation of evidence-based practices in delivery of patient care. Support and facilitate critical thinking of staff. Develop, maintain, and monitor staffing plans for assigned areas to ensure needs are met. Participates in recruitment and maintains adequate numbers of competent staff to provide care and meet patient care standards. Facilitate the orientation of new staff and the continuing education and professional development of existing staff. Assure staff have current licenses, certifications and are competent to provide care. Manage and lead staff to develop collaborative working relationships within department and with other departments as applicable. Collaborates with human resources to provide counseling or performance improvement of staff as needed. Support and develop the staff to ensure availability to participate in shared governance at the unit and organizational level. Assist nursing and practice leadership in managing and implementing departmental programs and goals that support the strategic plan for the organization and for patient care services. Support departmental implementation of new technology, services, and ongoing improvement. Effectively communicate (written & oral) across the organization. Performs other related duties as assigned or requested. Qualifications Your qualifications should include: Bachelor of Science in Nursing (or BSN not required if holds MSN) Minimum of 3 years of experience in an area of expertise relevant to the department with demonstrated progressive leadership growth California RN license (must obtain within 6 months of hire) American Heart Association-Basic Life Support (BLS) National Certification (must be acquired within 12 months of hire or transfer) Chemotherapy/Biotherapy certification preferred City of Hope employees pay is based on the following criteria: work experience, qualifications, and work location City of Hope is an equal opportunity employer. To learn more about our Comprehensive Benefits, please click here Primary Location: United States-California-IrvineJob: NursingWork Force Type: OnsiteShift: DaysJob Posting: Dec 19, 2025Minimum Hourly Rate ($): 63. 200600Maximum Hourly Rate ($): 105. 544800

Voted one of the best companies to work for by Modern Healthcare Magazine: Renew Health Consulting Services is an award winning family company providing healthcare services including skilled nursing, assisted living and senior living communities. We believe that seniors are extraordinary people. Their lives are filled with achievements, contributions and wisdom. They have raised families, served their communities and country, lived history and ultimately set the stage for us. We are honored to provide their care, as they make the transition to the golden years, and when it becomes more challenging to care for one's self. From a short-term rehabilitation stay to long term nursing care, each of our clinical programs are designed to reduce hospitalizations so our patients can focus on achieving their individual care plan goals whether it's returning home or staying with us for their long term care needs Our commitment to superior quality of life is evident when you visit our family of centers. At our care center you will meet compassionate and professional team members who understand that finding the right skilled nursing setting and long-term care option could be difficult and confusing and are wanting to make a difference by providing the utmost care to genuinely help our patients and the community around them. If this sounds like a great fit for you, we would love to have you join our wonderful team! Compensation & Benefits: As a growing and essential company, we have many opportunities for growth and development within the medical industry and are committed to providing the resources and training you need. Pay is market competitive and negotiable based on your experience. Full-time employees will be eligible for a variety of comprehensive medical, dental, and vision insurance plans. Full-time employees will be eligible for Tuition Assistance. 401K. Travel Allowance The anticipated pay range for candidates who will work in California is $150K to $180K annually . The offered pay to a successful candidate will be dependent on several factors that may include but are not limited to years of experience within the job, years of experience within the required industry, education, etc. We are looking for full-time RN MDS Consultant Responsibilities: Responsible for visiting facilities in the assigned Region(s) on a regular basis and ensuring the accurate and timely submission of patient assessments, care planning, and billing processes that comply with the Patient-Driven Payment Model (PDPM). Conduct comprehensive assessments of patient's clinical needs and identify potential PDPM coding opportunities. Collaborate with interdisciplinary teams to develop patient-centered care plans that optimize clinical outcomes and maximize reimbursement under PDPM. Analyses and organizes PDPM and case mix data to ensure appropriate utilization of resources. Review medical documentation to ensure completeness, accuracy, and compliance with CMS regulations. Monitor and analyze PDPM-related data, including patient outcomes, revenue, and compliance metrics, and provide regular reports to senior leadership. Coordinate with MDS to ensure accurate completion of all MDS assessments and any supporting assessments or clinical documentation. Ongoing QA of medical records for the presence of supporting documentation for all items coded on the MDS. Provide education and training to staff on PDPM and related topics, including coding, documentation, and care planning Serve as a subject matter expert on PDPM to internal and external stakeholders, including regulatory bodies, payers, and auditors. Participate in quality improvement initiatives to enhance patient care and optimize reimbursement under PDPM. Maintain up-to-date knowledge of PDPM regulations and industry best practices and share this information with the facility and management. Qualifications: Bachelor's degree in nursing or related clinical field Active RN license or relevant clinical licensure. Experience with MDS completion preferred. Minimum of 3-5 years of clinical experience in a healthcare setting. Experience with Federal Medicare Skilling and Long term care billing. In-depth knowledge of the PDPM reimbursement system and CMS regulations. Submit your application and join our award-winning team! We are an equal opportunity employer and we are committed to Equal Employment Opportunity regardless of race, color, national origin, gender, sexual orientation, age, religion, veteran status, disability, history of disability or perceived disability, and per the Fair Chance Ordinance will consider qualified applications with criminal histories in a manner consistent with the ordinance. INDHP JOB CODE: Renew

Your Role The Care Management team coordinates, educates, and advocates care for the Dual-Special Needs (DSNP) population with Blue Shield of California. The Case Management - Nurse, Senior will report to the Manager of Care Management within Medical Care Solutions. In this role you will be responsible for managing a caseload of DSNP members, reviewing Health Risk Assessments and completing Individualized Care Plans, engaging members to reduce readmissions to the hospital, and supporting the DSNP care management team. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Your Knowledge and Experience Current CA RN License required Bachelor's of Science in Nursing or advanced degree preferred Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements Requires 5+ years' experience in nursing, health care or related field. 3+ years managed care experience preferred. Health insurance/managed care experience desired. Transitions of care experience preferred Excellent communications skills Your Work In this role, you will: Research and design treatment /care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type. Initiate timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all ages. Determine appropriateness of referral for CM services, mental health, and social services. Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD). Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases. Manage member treatment to meet recommended length of stay. Ensure DC planning at levels of care appropriate for the members' needs and acuity Assess members' health behaviors, cultural influences and clients belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers. Research opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC. Determine realistic goals and objectives and provide appropriate alternatives. Actively solicit client's involvement. Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjust plans or create contingency plans as necessary. Assess and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings. Develop appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Recognize need for contingency plans throughout the healthcare process. Develop and implement the plan of care based on accurate assessment of the members and current of proposed treatment.

*5 years WC Examiner experience *Medical understanding to find treatment plans *Must be available continually during disgnated work hours *Abliity to follow pre-established medical protocols *Strong verbal and written communication skills *Eastside of WA (Ideally, tri-cities) *Relational personality is a must *Bilingual (Spanish) is a plus *Manage nurses and staff clients accordingly Salary will be discussed during interview *Bonus *Excellent pay *Excellent benefits

Large and traveler friendly facility in Southern California is needing help in their Case Manager Team. Must have at least 2 year of experience, and are certified BLS and CA license are needed! Call Ventura Medstaff today for more details at ************.

About TRIUNE Health Group TRIUNE Health Group is a nationally recognized managed healthcare company with over 35 years of experience. As a mission-driven, second-generation family-owned business, we are dedicated to improving lives by reducing the impact of injuries, enhancing health and wellness, and lowering healthcare and workers' compensation costs. At TRIUNE, we believe that every team member is essential to our success. We foster a supportive and collaborative environment where employees are valued, empowered, and provided with the tools they need to thrive-both professionally and personally. Why Join TRIUNE Health Group as a Nurse Case Manager? Be part of a well-established, family-owned company that prioritizes people over profits. Experience our culture of People Helping People , where every team member is treated with dignity and respect. Enjoy the stability, support, and resources needed to succeed while maintaining a healthy work-life balance. Perks & Benefits: Generous Time Off: 20 days of vacation plus 8.5 paid holidays Retirement Savings: 401(k) match to help you plan for the future Comprehensive Insurance: Medical, dental, and vision coverage Disability Coverage: Short-Term (STD) and Long-Term Disability (LTD) insurance Employee Support: Employee Assistance and Referral Program Work-from-Home Essentials: Home office equipment, including a laptop and desktop monitor Travel Perks: Mileage and travel reimbursement TRIUNE Health Group is an equal opportunity employer and a values-driven organization. Compensation is competitive and commensurate with experience. I. Summary of Position: The Nurse Case Manager coordinates resources and creates flexible, cost-effective options for catastrophically or chronically ill or injured individuals to facilitate quality, individualized, holistic treatment goals, including timely return to work when appropriate. II. Essential Duties and Responsibilities: Provide medical case management to individuals through coordination with the patient, physicians, other health care providers, the employer, and the referral source. Utilize the steps of Case Management to provide assessment, planning, implementation, evaluation, and outcome of an individual's progress. Evaluate individual treatment plans for appropriateness, medical necessity, and cost-effectiveness. Facilitate care, such as negotiating and coordinating the delivery of durable medical equipment and home health services, ensuring clear communication. Assess rehabilitation facilities for appropriateness of care, facilitate transportation, and coordinate architectural assessments of patients' homes when required. Communicate medical information clearly and compassionately to patients and families. Stay current with medical terminology and the federal and state laws related to health care, Workers' Compensation, ADA, HIPAA, FMLA, STD, LTD, SSDI, and SSA. Utilize technology (computer, cell phone, fax, and scanning machine) to prepare organized, timely reports while complying with safety rules and regulations in conjunction with HIPAA. Research medical and community resources for individuals with catastrophic or chronic diagnoses, such as but not limited to AIDS, cancer, spinal cord injuries, diabetes, head injuries, back injuries, hand injuries, and burns, ensuring accessibility for individuals. Possess a valid driver's license with the ability to travel 90% of the time. Perform other duties as assigned. III. Job Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Skills and Abilities: Proven leadership skills. Excellent verbal and written communication skills, including the ability to interact effectively with patients, customers, and fellow employees via phone, email, in-person, and formal presentations. Methodical in accomplishing job-related goals. Strong analytical and organizational skills, including the ability to multitask with attention to detail. In-depth knowledge of multi-software packages, notably Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and the Internet. Maintain a friendly, professional attitude at all times. Exercise initiative and be solution-oriented, while keeping management up-to-date on current situations or opportunities. Dependability and adaptability. Education and Experience: Graduate of an accredited school of nursing. Current RN licensure in the state of operation. Fluency in English (speaking, reading, and writing). Three or more years of recent clinical experience, preferably in trauma, psychology, emergency, orthopedics, rehabilitation, occupational health, and neurology. CCM preferred. Certificates, Licenses, Registrations: While not mandatory, individuals with one or a combination of the following certifications are preferred: COHN, COHN-S, and CDMS. IV. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The base salary range/hourly rate listed is dependent on job-related, non-discriminatory factors such as experience, education, and skills. This position is also eligible for incentive compensation awards. You may be eligible for the following competitive benefits: medical, dental, vision, life, accident & disability, short and long-term disability, paid holidays, paid time off and 401 (k). bination of the following certifications is preferred: COHN, COHN-S, CCM, and CDMS.

Prior Authorization Temp Nurse Case Manager, RN Northridge, CA 4\-Month Contract Assignment Quick On\-Boarding\/Placement Process Career Stepping Stone from Bedside Nursing to Case Management (acute care experience and working knowledge of pre\-auth process required) Description The role of the Prior Authorization Nurse Case Manager (PACM) is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests. The PACM will review for appropriate care and setting, and following guidelines\/policies, will approve services when indicated. If not indicated, PACM will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed. 1. Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting. 2. Communicate effectively and interact with providers, staff and health plans daily regarding medical management and referral authorization issues. 3. Maintain a working relationship with PACM colleagues, the pre\-auth coordinator team, high\-risk nurse case managers, inpatient nurse case managers, medical directors, and network management. 4. Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care\/setting, in order to provide right care\/right setting. 5. When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs\/specialists\/ancillary), and the members\/families. 6. Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence\-based or consensus guidelines, and health plan and CMS guidelines and\/or medical policies. 7. Maintain regulatory Turnaround Time Standards per regulatory guidelines. 8. Document accurately and completely all necessary information in authorization notes. 9. Understand all applicable capitation contracts and how they apply to review duties. 10. For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed. 11. When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.). 12. Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner. 13. Participates in “service recovery” through follow\-up with an upset patient or provider, gathering information, and demonstrating empathy. 14. Identifies network needs and report to management for potential contracting opportunities. Qualifications 1.Graduate from an accredited Registered Nursing Program 2.Current California RN License 3.Minimum of 1 year acute experience 4.Knowledge of Managed Care preferred. 5.Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management. 6.Knowledgeable with the pre\-authorization process and workflow, with prior authorization experience preferred. 7.Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point). 8.Ability to deal with responsibility with confidential matters 9.Ability to work in a multi\-tasking, fast\-paced, high\-stress environment. Compensation $38\-$42\/Hr Negotiable based on experience "}}],"is Mobile":false,"iframe":"true","job Type":"Temporary","apply Name":"Apply Now","zsoid":"59877574","FontFamily":"PuviRegular","job OtherDetails":[{"field Label":"Industry","uitype":2,"value":"Health Care"},{"field Label":"Work Experience","uitype":2,"value":"1\-3 years"},{"field Label":"Salary","uitype":1,"value":"$38\-$42\/Hr"},{"field Label":"City","uitype":1,"value":"Northridge"},{"field Label":"State\/Province","uitype":1,"value":"California"}],"header Name":"Prior Authorization Temp Nurse Case Manager","widget Id":"**********00072311","is JobBoard":"false","user Id":"**********02463003","attach Arr":[],"custom Template":"5","is CandidateLoginEnabled":false,"job Id":"**********00327001","FontSize":"15","location":"Northridge","embedsource":"CareerSite","indeed CallBackUrl":"https:\/\/recruit.zoho.com\/recruit\/JBApplyAuth.do"}

Job DescriptionBenefits: 401(k) matching Dental insurance Employee discounts Free uniforms Health insurance Paid time off Training & development Vision insurance If you like to innovate, are self-reliant with a strategic mind and forward-thinking solutions approach and interested in giving your full potential and grow with us, this position may be for you. We are a social and environmental responsible Company. Our commitment to quality, continuous improvement, safety, community, belonging and adaptability are part of our personality. We are looking for a proactive, independent and highly qualified Third Party Coordinator who can lead all design and construction activities and interact with third-party agencies that hold Authority Having Jurisdiction (AHJs) over LAWA, assisting the Third-Party Lead in facilitating their efforts. Essential Job Duties Assist the Third-Party Lead in coordinating with city, county, state agencies, and utilities. Represent the City when interacting with private engineers, contractors, governmental agencies, and the public. Manage activities between developers/contractors and third parties. Assist the Third-Party Lead in developing reporting mechanisms to track third-party progress. Provide progress updates on efforts in coordinating third-party activities. Attend and participate in third-party progress meetings at various locations virtually, at Project Management Offices, in the field, or at the third-party offices (several are in downtown Los Angeles). Prepare meeting agendas, minutes, and action items. Track action items to completion as they relate to third parties. Act as a utility coordinator between utility companies, contractors, and the LAWA. Attend utility design, engineering, and construction coordination meetings, as needed, and provide insight regarding stakeholder requirements and ensure compliance. Act as a liaison between squads, sections, divisions, and departments. Support and advise project teams, particularly regarding coordinating logistics and interfaces with third parties. Support Third Party Lead and Logistics and Interface Managers in other efforts, as required. Prepare and review technical reports and written correspondence. Review general project requirements, design criteria, and contract requirements. Ensure that monthly reports describing activities associated with Third Party Coordination are prepared and forwarded to the project management team. Develop presentations describing third-party updates, including key accomplishments, ongoing coordination activities, and issues for project management teams. Participate in negotiations with regulatory agencies and in public meetings in support of LAWA Contribute to advancing LAWAs goals through commitment to productive collaboration with all stakeholders. Safety principles and practices Hardware/Software Knowledge Proficiency with Microsoft systems, including Outlook, Excel, Word, PowerPoint, OneNote, Teams, SharePoint, Prolog or other similar PMIS, Adobe Acrobat or Bluebeam Revu, Familiarity with Primavera P6 or other Scheduling Software. Familiarity with MicroStation and/or Autodesk systems, including AutoCAD, Revit, Civil 3D, and BIM 360. Professional Experience Level/Other Qualifications 10 years or more experience with third party coordination in Los Angeles. Local experience with agencies such as the City and County of Los Angeles, CPUC, Caltrans, Metro, or City of Inglewood. Familiarity with industry practices, codes, and regulations. Thorough understanding of airport-specific enterprise-wide challenges and inherent communications needs. Excellent written and verbal communication, organizational, and interpersonal skills are required. Be familiar with the Department of Public Works and LADBS permitting processes. Education/Training Bachelors degree in Engineering, Project Management, Business , or other related technical field. A Masters degree is preferred. Element-Specific Requirements/Notes May assume other duties as required/needed May be required to work various shifts as needed May be required to travel to the field and PMOs This position offers a hybrid/telework schedule. Telework - Monday and Friday. Onsite - Tuesday, Wednesday and Thursday. Please refer to LAWAs Pilot Policy for details Registration/Certification Optional Certifications may include AAAE, LEED, PMP, PE, AICP, PMI-SP etc. or any other relevant Professional Licensure or Certifications. Registration as a Professional Engineer with the California State Board of Registration for Professional Engineers is preferred.