RN Lead Utilization Management Oversight Specialist - FT - 249C

Job Description

The Utilization Management (UM) Specialist Position ensures compliance of the Plan Partners and/ or Participating Physician Groups (PPG) to regulatory, contractual and LA Care requirements. The UM Specialistis responsible for performing annual and focused audits and continuous monitoring activities. This position.

Also acts as a liaison between the Plan Partners and/ or PPGs and L. A. Care Health Plan regarding UMissues. The position assists in improving access and utilization performance of Plan Partners and/ or PPGs by being a resource for best practices and providing continuous feedback.

Additionally, the oversight responsibility of this position includes attendance at Plan Partner and/ or PPG UM Committees and Joint Operational Meetings (JOMs), monitoring of supplemental UM reports, reporting to management and UMC and consultation/ instructional/ coaching activities to improve overall compliance of Plan Partners and PPGs with all regulations and standards.

Qualifications

EDUCATION

Required: Associate's Degree or Bachelor's Degree in RN

Preferred: Bachelor's Degree in Nursing or Related Field.

LICENSES/CERTIFICATIONS

Required: Registered Nurse with active, current, unrestricted California RN license, and Valid California Driver's license.

Preferred: Case management certification

Special Instructions

Req. Number: 249C