Utilization Management & Quality Review Nurse

Description

As the Utilization Management & Quality Review Nurse, you will be responsible for:

• Ensuring appropriate, cost-effective, and high-quality care for New Century Health Plan members

• Conducting utilization management (UM) activities in accordance with health plan policies and regulatory guidelines

• Identifying and reporting Potential Quality Issues (PQI) and supporting Provider Dispute Resolution (PDR) processes to ensure compliance and foster provider satisfaction

• Completing other duties as assigned

Salary Range: $61.79 - $79.91/hourly

Qualifications

We're seeking a highly qualified candidate with:

• A BSN or MSN degree, required

• Current valid California RN license, required

• Two or more years of experience in utilization management, preferably in Medicare Advantage or managed care

• Knowledge of Medicare Advantage regulatory guidelines, including CMS regulations

• Experience with Potential Quality Issues (PQI) identification and reporting

• Familiarity with Provider Dispute Resolution (PDR) processes

• Strong clinical assessment and critical thinking skills

• Proficiency in electronic health records (EHR) and utilization management software

• Excellent written and verbal communication skills

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.