Utilization Management Oversight & Compliance Specialist, RN

LA Care Health Plan   •  


Industry: Healthcare IT


5 - 7 years

Posted 386 days ago

Job Title:Utilization Management Oversight & Compliance Specialist, RN Job Category:Clinical / Non-Clinical Department:Clinical Assurance Location:Headquarters, Downtown Los Angeles Position Type:Full-time Position Control Number:250B Pay Grade:K

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The Utilization Management Oversight & Compliance Specialist, RN is responsible for assuring that the UM Department is in compliance with all UM regulatory requirements and new legislation through the maintenance of required policies/procedures/workflows/ processes/audit tools necessary to meet the requirements. It is expected that the Senior UM Oversight will utilize the rapid team approach for needed system improvements identified through internal or external audits or other oversight monitoring activities.  This position assist in  maintaining continuous quality improvement in UM, ensuring that departmental/divisional and organizational goals are accomplished through overseeing and facilitating compliance of the Plan Partners and contracted provider network.  This is expected to be accomplished through the facilitation of data flow, analysis, reporting,  and recommending alternatives/solutions for improvement both internally and externally.  It is responsible, as part of the oversight team, for ensuring compliance of the Plan Partners and/or Participating Physician Groups (PPG) to regulatory, contractual and LA Care requirements. The Senior UM Oversight Specialist is responsible for performing annual and focused audits and continuous monitoring activities. This position also acts as a liaison between the Plan Partners and PPGs and L. A. Care Health Plan regarding UM issues.  The position assists in improving access and utilization performance of Plan Partners and PPGs by being a resource for best practices and providing continuous feedback.  Additionally, the oversight responsibility of this position includes attendance at Plan Partner and PPG UM Committees and Joint Operational Meetings (JOMs), monitoring of supplemental UM reports, reporting to management and UMC and consultation/instructional/coaching activities to improve overall compliance of Plan Partners and PPGs with all regulations and standards.


Associate's Degree or Bachelor's Degree in RN
Bachelor's Degree in Nursing or Related Field.
Registered Nurse with active, current, unrestricted California RN  license
5 years in a clinical setting with at least three (3) years in a managed care setting in Utilization Management/Case Management;  
Knowledge of issues pertaining to Medi-Cal and other HMO & IPA contracts, & payers;  
Ability to manage and organize large volumes of data; 
Knowledge of accreditation entities and their  requirements;  
Excellent verbal and written communication skills and excellent interpersonal skills;
Good working knowledge of regulatory requirements/standards;
Ability to work independently;
Ability to solve complex issues and identify creative solutions;
Computer ease & literacy with Word, Excel, PowerPoint Skills.