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Utilization Management Quality Improvement Nurse

Yoh Torrance Full-Time
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Utilization Management Quality Improvement Nurse needed for a DIRECT HIRE opportunity with Yoh’s client located in Los Angeles, CA (South Bay)

Top Skills Should You Possess:

  • Current, unrestricted California RN license
  • Bachelor’s degree in nursing or related field preferred
  • One to two years of UM and UM auditing experience
  • Working knowledge of Medicare ODAG and Medicare Advantage Part C report requirements and scheduling
  • Knowledgeable of health plan requirements, DMHC, DHCS and CMS regulatory guidelines related to UM processes
  • Experience with NCQA standards and review process
  • Knowledge of CMS Conditions of Participation
  • Knowledge of The Patient Bill of Rights

What You’ll Be Doing:

  • Analyze authorizations and denial letters in accordance with California Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) standards
  • Perform internal and external communications to obtain needed information and verification of data related to audits or report submissions to the health plans
  • Review and assist Physician Reviewers in composing denial reasons to ensure the denial reason language is clear and concise and citing correct clinical criteria and utilizes the correct product specific grade level language
  • Prepare summary reports of audit findings to help initiate and identify needed corrective action plans
  • Prepare and review health plan pre-audit documents and collaborate with Compliance Manager as well as UM Manager for pre-audit documents submission
  • Validate Medicare Organization Determinations, Appeal, and Grievances (ODAG) and Medicare Advantage Part C reports with Senior UM Nurse prior to submission to health plans
  • Prepare for and participate in health plan audits, pre-audit documentation submissions and corrective action plans based on health plan audit findings with Compliance Manager as well as UM Manager
  • Identify opportunities for improvement in UM processes and collaborate with UM Manager to develop improvement plans and training programs
  • Conduct staff training related the UM delegated activities under the direction of UM Manager
  • Review and prepare case summaries for member grievances related to potential quality of care issue
  • Provide collaborative support for organization of quarterly CQI meetings and quarterly/semiannual work plans

What You Need to Bring to the Table:

  • Skilled in MSWord, Excel, Electronic Health Records, Medicare and Milliman guidelines
  • Strong analytical, organization and time management skills
  • Excellent verbal and written communication skills

This position offers a competitive salary, generous employee benefits, and paid time off, and the opportunity to be a part of the award winning Health System. APPLY NOW!

Recruiter: Marine Kokoshyan

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Job ID: BHJOB18230_236422


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