Job Description
Description
Take on a high-impact role within a world-class health organization. Help drive the continued delivery of exceptional patient care. Take your career to the next level. You can do all this and more at UCLA Health.
You will play a key part in promoting high-quality, cost-effective medical care by applying clinical acumen and applicable policies and guidelines in the issuance of adverse organization determinations. You will review for appropriate care and setting while working closely with denial coordinators and other staff to ensure the accurate processing of all written notifications. You will also provide clinical guidance on denial cases and ensure that all denial letters are written and issued according to internal policies and NCQA, health plan, federal, and state requirements.
Salary Range: $63,800 - $127,000/annually
Qualifications
We're seeking an exceptionally gifted, self-motivated leader with:
+ Current CA LVN licensure required
+ Two or more years of utilization review/utilization management experience in an HMO, MSO, IPA, or health plan environment
+ Previous clinical experience
+ Experience drafting and issuing compliant adverse organization determinations
+ In-depth knowledge of health plan, DMHC, CMS, HIPPA, and NCQA requirements
+ Expertise in abstracting and interpreting medical information from patient records
+ Strong communication, interpersonal, analytical, problem-solving, organizational, and prioritizing skills
+ Thorough understanding of the Hierarchy of Clinical Criteria
+ Experience with Flesch-Kincaid readability scoring
+ Knowledge of the appeals process
+ Experience with audit preparation
+ Basic computer skills
UCLA Health is a world-renowned health system with four award-winning hospitals and more than 250 community clinics throughout Southern California as well as the David Geffen School of Medicine. Through the efforts of our outstanding people, we have become Los Angeles' trusted provider of exceptional, compassionate patient care. If you're looking to experience greater challenge and fulfillment in your career, you can at UCLA Health.
UCLA Health welcomes all individuals, without regard to race, sex, sexual orientation, gender identity, religion, national origin or disabilities, and we proudly look to each person's unique achievements and experiences to further set us apart.
Job Tags
Similar Jobs
AppleOne
...benefits-related inquiries and issues. -Maintain accurate and up-to-date employee records. -Ensure confidentiality and security of HR information. -Prepare and submit required reports to regulatory agencies. -Ensure compliance with all applicable employment laws...
Pfizer
...RWE and epidemiology studies as part of cross-functional IEPs.+ Provide subject matter expertise and thought leadership to advance Pfizer's use of RWE/Epi to develop high value medicines.+ Partner with TA RWE/Epi lead and MEG TA Leads to ensure strategic input is...
System One
System One is looking for Quality Engineers to support or clients Quality Team in the design and manufacture of highly engineered... ...legally authorized to work permanently in the U.S. without visa sponsorship now or in the future. ~ Strong critical thinking and problem...
Arcadis
...Required Qualifications: ~ Bachelors degree in Civil Engineering, Environmental Engineering, or related field. Preferred Qualifications:... ..., disability, veteran status, or any other basis prohibited by law. Arcadis offers benefits for full time and part time...
Summit Strive Consulting
...Job Description: We are seeking a passionate and driven Community Liaison to join our team. As a vital link between our organization... ...the community about our services and initiatives Track outreach activities, maintain records, and provide regular reports to management...