Utilization Management & Quality Review Nurse

General Information

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Work Location: Los Angeles, USA Onsite or Remote Flexible Hybrid Work Schedule Monday-Friday, 8:00am-5:00pm PST Posted Date 10/30/2024 Salary Range: $61.79 - 79.91 Hourly Employment Type 2 - Staff: Career Duration Indefinite Job # 20146

Primary Duties and Responsibilities

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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 

Job Qualifications

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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