Utilization Management Oversight Nurse Specialist - FT - 1152A

Job Description

The Utilization Management Specialist Position ensures compliance of the participating physician groups (PPGs) with regulatory, contractual and LA Care requirements. The UM Specialist is responsible for performing annual and focused audits and continuous monitoring activities. This position also acts as a liaison between the PPGs and L. A. Care Health Plan regarding UM issues, and assists in improving access and utilization performance of  PPGs by being a resource for best practices and providing continuous feedback.  

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

Qualifications

EDUCATION

Required: Associate's Degree in Nursing or Related Field

Preferred: Bachelor of Nursing or health care related field

LICENSES/CERTIFICATIONS

Required:Current and unrestricted CA RN License

EXPERIENCE

Required: 5 years of previous experience in a managed care health plan performing UM oversight, including auditing.  Managed health care experience.

Good working knowledge of regulatory requirements/standards.

Excellent verbal and written communication skills Excellent interpersonal skills   

Proficiency with MS Office Application, such as MS Word, Excel, and PowerPoint

Ability to work independentlyAbility to solve complex issues and identify creative solutions.

Preferred:  Project management skills

Special Instructions

Req. Number: 1152A