RN Job
Utilization Management Claims Review Nurse RN II
Job Description
The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards.
This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA).
The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements.
Qualifications
Education Required:
- Associate's Degree in Nursing
Preferred:
- Bachelor's Degree in Nursing
Experience Required:
- At least 5 years of experience in Clinical Nursing.
- At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.
- Experience in performing and creating clinical documentation.
- Experience in regulatory compliance for a health plan.
Preferred:
- Experience with Provider Dispute Review (PDR) processes.
- Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes.
- Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring.
About the Hospital
As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.
Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.
