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General Information

Work Location: Los Angeles, USA
Onsite or Remote
Flexible Hybrid
Work Schedule
Monday - Friday, 8:00am - 5:00pm PST
Posted Date
03/26/2024
Salary Range: $63800 - 127000 Annually
Employment Type
2 - Staff: Career
Duration
indefinite
Job #
9333

Primary Duties and Responsibilities

Take on a high-impact role within a world-class health organization. Help drive the continued delivery of exceptional patient care. Take your career to the next level. You can do all this and more at UCLA Health.

You will play a key part in promoting high-quality, cost-effective medical care by applying clinical acumen and applicable policies and guidelines in the issuance of adverse organization determinations. You will review for appropriate care and setting while working closely with denial coordinators and other staff to ensure the accurate processing of all written notifications. You will also provide clinical guidance on denial cases and ensure that all denial letters are written and issued according to internal policies and NCQA, health plan, federal, and state requirements.


Salary Range: $63,800 - $127,000/annually

Job Qualifications

We’re seeking an exceptionally gifted, self-motivated leader with:

  • Current CA LVN licensure required
  • Two or more years of utilization review/utilization management experience in an HMO, MSO, IPA, or health plan environment
  • Previous clinical experience
  • Experience drafting and issuing compliant adverse organization determinations
  • In-depth knowledge of health plan, DMHC, CMS, HIPPA, and NCQA requirements
  • Expertise in abstracting and interpreting medical information from patient records
  • Strong communication, interpersonal, analytical, problem-solving, organizational, and prioritizing skills
  • Thorough understanding of the Hierarchy of Clinical Criteria
  • Experience with Flesch-Kincaid readability scoring
  • Knowledge of the appeals process
  • Experience with audit preparation
  • Basic computer skills

UCLA Health is a world-renowned health system with four award-winning hospitals and more than 250 community clinics throughout Southern California as well as the David Geffen School of Medicine. Through the efforts of our outstanding people, we have become Los Angeles’ trusted provider of exceptional, compassionate patient care. If you’re looking to experience greater challenge and fulfillment in your career, you can at UCLA Health.

As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.