Utilization Management & Quality Review Nurse

University of California - Los Angeles Health
United States, California, Los Angeles
Feb 12, 2025
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