Utilization review nurse jobs in Hawaiian Gardens, CA - 346 jobs

Event Details Join us for an Interview and Hiring Day! Registered Nurses welcomed! Time: 9:00 am to 2:00 pm Directions/Parking: Our main lobby entrance is located at 1680 E 120th Street, Los Angeles, CA 90059. The entrance to the parking lot is on Healthy Way at the north side of our building, behind the large sculpture. Our hospital is easily accessible by public transportation and car. Please note: Interview times are first come first serve and you will be required to check in once you arrive at the event. Click RSVP Now to get started This event is for experienced Registered Nurses. Here's why it's great to be a nurse at MLKCH MLK Community Healthcare has a culture of nursing like no other. We have a compelling mission to improve the health of an appreciative and truly deserving community. We support our nurses with tools, training and best-in-class resources. Our fantastic new RN Residency Program launches recent graduates on a path to success. Our staff fellowships for experienced nurses open doors to new fields of expertise and leadership training at the highest level. And we offer competitive pay and unbeatable benefits. The result? Inspirational careers and the chance to make a meaningful difference in the lives of the most vulnerable.

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.

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 ******************.

Virtual: 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. 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. Work schedule: Monday - Friday 9:30am - 6pm local time, with rotating weekends. (Saturday 8am-12pm CST, with a comp day during the week) 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: * Requires 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, PPO and POS plans strongly preferred. * BA/BS degree preferred. * Previous utilization and/or quality management and/or call center experience preferred. * RN Compact License is strongly preferred; CA RN License is also preferred. * Experience in cardiology/radiology is preferred but not required. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $36.27 to $56.77 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. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse 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

Virtual: 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. 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. Work schedule: Monday - Friday 9:30am - 6pm local time, with rotating weekends. (Saturday 8am-12pm CST, with a comp day during the week) 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: Requires 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, PPO and POS plans strongly preferred. BA/BS degree preferred. Previous utilization and/or quality management and/or call center experience preferred. RN Compact License is strongly preferred; CA RN License is also preferred. Experience in cardiology/radiology is preferred but not required. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $36.27 to $56.77 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. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse 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.

TYPE OF RECRUITMENT: OPEN COMPETITIVE JOB OPPORTUNITY EXAM NUMBER: Y5126D This examination will remain open until the needs of the service are met and is subject to closure without prior notice. ABOUT LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES The Los Angeles County Department of Health Services (DHS) is the second largest municipal health system in the nation. Through its integrated system of 25 health centers and four (4) acute hospitals and expanded network of community partner clinics - DHS annually provides direct care for 600,000 unique patients, employs over 23,000 staff, and has an annual budget of over $6.9 billion. Through academic affiliations with the University of California, Los Angeles (UCLA), the University of Southern California (USC), and the Charles R. Drew University of Medicine and Sciences (CDU), DHS hospitals are training sites for physicians completing their Graduate Medical Education in nearly every medical specialty and subspecialty. In addition to its direct clinical services, DHS also runs the Emergency Medical Services (EMS) Agency and the County's 911 emergency response system, as well as Housing for Health and the Office of Diversion and Re-entry, each with a critical role in connecting vulnerable populations, including those released from correctional and institutional settings, to supportive housing. For additional information regarding DHS please visit ******************** MISSION: To advance the health of our patients and our communities by providing extraordinary care. DEFINITION: Exercises, under medical direction, administrative and technical supervision over the nursing staff engaged in utilization review activities at Los Angeles General Medical Center, one of the largest public hospitals in the country with 600-beds. CLASSIFICATION STANDARDS: The position allocated to this class is responsible for directing, through subordinate supervisors, the activities of the Utilization Review Nurses engaged in utilization review activities, in accordance with the Professional Standards Review Organization guidelines and the Joint Commission on Accreditation of Hospitals' utilization review standard. Under the direction of a physician member of the Utilization Review Committee, the incumbent is responsible for the development and implementation of procedures for and the effective conduct of the system to review patients' medical charts to ascertain the medical necessity for services and appropriateness of the level of care, for notification of appropriate persons of cases which do not meet medical necessity and level of care criteria, and for certification of approved hospital days reimbursable under the Medicare and MediCal programs. * Plans, develops, and implements procedures to fulfill the Professional Standards Review organization requirements for an effective and timely utilization review system. * Directs the utilization review function through subordinate supervisors, conferring with supervisors on personnel, and technical and administrative problems. * Reviews and analyzes reports prepared by subordinate supervisors 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. * 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. * Evaluates the performance of subordinate supervisors and reviews their evaluations of Utilization Review Nurses; counsels subordinates on their performance. * Develops procedures for the compilation of information from medical charts concerning diagnoses, problems, procedures, or practitioner categories as directed for medical care evaluation studies. * Works with Professional Standards Review Organization representative to orient new staff to Federal laws and regulations pertaining to Medicare and Medi-Cal reimbursement. * 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. * 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. SELECTION REQUIREMENTS: 1. One (1) year experience within the last five (5) years in the supervision* of nursing staff engaged in utilization review activities. * AND- 2. Current certification issued by the American Heart Association's Basic Life Support (BLS) for Healthcare Providers (CPR & AED) Programs. LICENSE(S) AND CERTIFICATE(S) REQUIRED: A current license to practice as a Registered Nurse issued by the California Board of Registered Nursing. Applicants must ensure the License and Certification Section of the application is completed. Provide the title(s) of your required license(s), the number(s), date(s) of issue, date(s) of expiration and the name(s) of the issuing agency for the required license as specified in the Selection Requirements. Applicants claiming experience in a state other than California must 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. Required license(s) and/or certification(s) must be active and unrestricted, or your application will not be accepted. Additionally, in order to receive credit for license(s) and/or certification(s) in relation to any desirable qualifications, the license(s) and/ or certification(s) must be active and unrestricted. A current certification issued by the American Heart Association's Basic Life Support (BLS) for Healthcare Providers (CPR & AED) Program. Applicants MUST attach a legible photocopy of the required BLS certification to their application at the time of filing or within 15 calendar days of filing your application online. Applications submitted without the required evidence of BLS certification will be rejected. PHYSICAL CLASS II: Light: Light physical effort which may include occasional light lifting to a 10-pound limit, and some bending, stooping or squatting. Considerable walking may be involved. SPECIALTY REQUIREMENTS: * For this examination, supervision MUST include all the following: planning, assigning, reviewing work of staff and evaluating employee performance. DESIRABLE QUALIFICATIONS: Credit will be given to applicants who possess the following desirable qualifications: * Experience within the last five (5) years in the supervision* of nursing staff engaged in utilization review activities beyond the selection requirements. * Bachelor of Science degree in Nursing (BSN) or higher from an accredited institution. In order to receive credit for any type of college degree, you MUST include a legible copy of the official degree, official transcripts, or official letter from the accredited institution which shows the area of specialization WITH your online application at the time of filing, or within 15 calendar days from the date of filing the application.EXAMINATION CONTENT The examination will consist of an evaluation of education and experience based upon application information and Desirable Qualifications, weighted 100% Candidates must achieve a passing score of 70% or higher on the examination in order to be placed on the eligible register. Notification Letters and other correspondences will be sent electronically to the email address provided on the application. It is important that applicants provide a valid email address. Please add ************************** and *********************** to your email address book and to the list of approved senders to prevent email notifications from being filtered as SPAM/JUNK mail. ELIGIBILITY INFORMATION: The names of candidates receiving a passing grade in the examination will be placed on the eligible register in the order of their score group for a period of twelve (12) months from the date of promulgation. Applications will be processed on an as received basis and promulgated to the eligible register accordingly. No person may compete for this examination more than once every twelve (12) months. AVAILABLE SHIFT: Appointees may be required to work any shift, including evenings, nights, weekends and holidays. VACANCY INFORMATION: The resulting eligible register for this examination will be used to fill a vacancy at the Comprehensive Health Centers and its affiliated Health Centers and any other vacancies throughout the Department of Health Services as they occur. APPLICATION AND FILING INFORMATION: Applications must be filed online only. Applications submitted by U.S. mail, fax, or in person will not be accepted. The acceptance of your application depends on whether you have clearly shown that you meet the SELECTION REQUIREMENTS. Fill out your application and supplemental questionnaire completely and correctly to receive full credit for related education and/or experience in the spaces provided so we can evaluate your qualifications for the job. Please do not group your experience, for each position held, give the name and address of your employer, your position title, beginning and ending dates, number of hours worked per week, and description of work performed. If your application is incomplete, it will be rejected. IMPORTANT NOTES: * All information supplied by applicants and included in the application materials is subject to VERIFICATION. * We may reject your application at any time during the examination and hiring process, including after appointment has been made. * FALSIFICATION of any information may result in DISQUALIFICATION or RECISSION OF APPOINTMENT. * Utilizing VERBIAGE from Class Specification and/or Selection Requirements serving as your description of duties WILL NOT be sufficient to demonstrate that you meet the requirements. Comments such as "SEE RESUME" or "SEE APPLICATION" will not be considered as a response; in doing so, your application will be REJECTED. NOTE: Candidates who apply online must upload any required documents as attachments during application submission. If you are unable to attach required documents, you may email the documents to Alvonte Harraway at ************************** at the time of filing, or within 15 calendar days from the date of filing the application. Please include your Name, the Exam Number and Exam Title on the email. SOCIAL SECURITY NUMBER: Please include your Social Security Number for record control purposes. Federal law requires that all employed persons have a Social Security Number. FAIR CHANCE INITIATIVE: The County of Los Angeles is a Fair Chance employer. Except for a very limited number of positions, you will not be asked to provide information about a conviction history unless you receive a contingent offer of employment. The County will make an individualized assessment of whether your conviction history has a direct or adverse relationship with the specific duties of the job, and consider potential mitigating factors, including, but not limited to, evidence and extent of rehabilitation, recency of the offense(s), and age at the time of the offense(s). If asked to provide information about a conviction history, any convictions or court records which are exempted by a valid court order do not have to be disclosed. NO SHARING OF USER ID AND PASSWORD: All applicants must file their applications online 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. ADA Coordinator Phone: ************** California Relay Services Phone: ************** DEPARTMENT CONTACT: Alvonte Harraway, Exam Analyst HR ESC phone number is ************** **************************

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen-not dilute-our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. Job Description: SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas, New Mexico & Washington. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit ********************* *********************** or follow us on LinkedIn, Facebook, and Twitter. The Job Provide clinical review of medical claims and post service appeals. Facilitate appropriate investigation of issues and management of medical services and benefits administration while maintaining SCAN timeframe standards. You Will Review and analyze pre and post payment of complex health care claims from a medical perspective. Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverages Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations Conduct review of claims data and medical records to make clinical decisions on the coverage medical necessity, utilization, and appropriateness of care per national and local policies as well as accepted medical standards of care) as assigned and as necessary and appropriate Process workload and complete project work in the appropriate computer system(s). Contribute to team effort by accomplishing related results as needed.Route identified clinical and/or risk issues to appropriate personnel eg, Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc Review/prepare potential claims denials in conjunction with Medical DirectorCollaborate with Medical Director pursuant to adjudication of claims and post service appeals Participate in special projects/workgroups/committees (eg, interdisciplinary workgroups, report analysis, independent review entity (IRE) etc. as assigned and as necessary and appropriate. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of SCAN's Vision and Goals. Other duties as assigned. Your Qualifications - Associate's Degree or equivalent experience required- Current and active California RN License in good standing required- Bachelor's Degree or equivalent experience preferred- Certified Professional Coder preferred.- 3-5 years of related experience in clinical decision making relative to Medicare patients.- Certifications deemed to be reasonable to function at this level.- Performs work under minimal supervision.- Handles complex issues and problems and refers only the most complex issues to higher-level staff.- Possesses comprehensive knowledge of subject matter.- Technical expertise - Strong technical skills for functional area - Problem Solving - Strong problem-solving skills - Communication - Good communication and interpersonal skills- Ability to work as part of a team. - Oral and written communication skills. - Problem-solving skills. - Attentiveness. - Interpersonal skills What's in it for you? Base salary range: $38.61 to $55.86 per hour Remote position An annual employee bonus program Robust Wellness Program Generous paid-time-off (PTO) Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday Excellent 401(k) Retirement Saving Plan with employer match and contribution Robust employee recognition program Tuition reimbursement An opportunity to become part of a team that makes a difference to our members and our community every day! We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now! At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. #LI-CS2 #LI-Remote Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

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

Department HS - UM Employment Type Full Time Location 1600 Corporate Center Dr., Monterey Park, CA 91754 Workplace type Hybrid Compensation $30.00 - $34.00 / hour Reporting To Sandra Castellon What You'll Do Qualifications Environmental Job Requirements and Working Conditions About Astrana Health, Inc. Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.

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

**Virtual:** 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. _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._ **Work schedule:** Monday - Friday 9:30am - 6pm local time, **with rotating weekends.** **(Saturday 8am-12pm CST, with a comp day during the week)** 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:** + Requires 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, PPO and POS plans strongly preferred. + BA/BS degree preferred. + Previous utilization and/or quality management and/or call center experience preferred. + RN Compact License is strongly preferred; CA RN License is also preferred. + Experience in cardiology/radiology is preferred but not required. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $36.27 to $56.77 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.

Job DescriptionBenefits: 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 Summary We 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 Veterans family, caregiver and/or significant other, the Veterans 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 Veterans 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 Veterans family, caregiver and/or significant other, the Veterans 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.

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.

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 a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. 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 The position of UM Outpatient Review Nurse reports to the Director, Case Management. The position of UM Outpatient Review Nurse is part of the Case Management team and is responsible for clinical, quality, and patient outcomes. This position is expected to implement the effectiveness and best practices of Utilization Review and will provide high quality medical review by appropriately applying the State, Federal, health plan and clinical guidelines used to determine medical necessity. Duties and responsibilities Review authorization requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed consent. Process all requests within established time frames. Documents all steps of process in authorization system in the authorization notes. Utilizes CMS and Health Plan Hierarchy criteria. Clinical documentation, specific criteria, and record attachment for referral prior to sending to the Medical Director for review. Retrospective review of services to determine medical necessity. Refer cases to the Medical Director for review of requests that may not meet medical necessity criteria. Process denials within established timeframes. Writes denial letters to meet CMS and Health Plan requirements. Work closely with other MSO team members as necessity requires. Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process. Review member's utilization and claim history when processing a referral. Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro requests. Maintains Interrater Reliability Rate at least 95% or above. Daily production standard is a minimum of 50-90 referrals/day depending on complexity with accuracy & quality. Makes approval determinations when request meets appropriateness, medical necessity and benefit criteria. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meet criteria and can be authorized by a nurse level reviewer. Act as clinical resource to all departments. Communicates with health plans, providers, members and other parties to facilitate member care treatment plans. Participating in team training Comply with UM policies and procedures. Annual review of UM policies. Attend to provider and interdepartmental calls in accordance with exceptional customer service. Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers, and members. Always maintains strict confidentiality. Other duties as needed. Qualifications Valid CA and Texas/Multi State Registered Nurse license, Licensed Vocational Nurse CM and/or UM training and/or certification. Knowledge of CM standards, UM standards, Clinical Standards of Care, NCQA requirements, CMS guidelines, Milliman guidelines, and InterQual guidelines. Medi-Cal, Commercial and Medicare contracts and benefit interpretation is preferred. Five years+ clinical experience. Prefer of two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended. Ability to work independently with minimal supervision, exercising judgment and initiative. Ability to manage multiple tasks with effective prioritization. Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe Detail oriented and highly organized Strong ability to multi-task, project management, and work in a fast-paced environment 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 Education and Additional Requirements Holds Current Unrestricted CA and Texas/Multi State RN or LVN license

The Nurse Reviewer is 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 the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. Schedule: This position is full time and must include every weekend Location: Virtual - This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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 accommodation is granted as required by law. 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: • Requires 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-10 and 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. For candidates working in person or virtually in the below locations, the salary* range for this specific position is $31.54 - $47.31 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. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse 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.

DescriptionAstrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a hybrid position where you will work at-home and in our Monterey Park office on a weekly basis. We are open to nurses without prior UM experience! Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN CA license. Experience with Microsoft applications such as Word, Excel, and Outlook You'll be Great for this Role If: Two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a hybrid position, where you will work at home and in-office on a weekly basis. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $30.00 - $34.00 per hour. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at ************************************ to request an accommodation. Additional Information:The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

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

Job Description 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