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Description
Quality Management Nurse Specialist
Work Location
Los Angeles,CA
Job #22893
Work Hours
Monday – Friday, 8:00am – 5:00pm PST
Employment Type
2 – Staff- Career
Duration
Indefinite
Salary Range
$36.49-76.05 Hourly
Posted Date
March 4, 2025
Bargaining Unit
99
Make a difference in people’s lives every day. When you join UCLA Health, you’ll be working at an institution that provides leading-edge care to the people of L.A. and throughout the world. We provide our team members with the environment and support to do amazing work, because each and every one of them plays a vital role in our commitment to care.
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JOB DUTIES
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JOB QUALIFICATIONS
Description
- Analyze and resolve complaints/appeals: Gather and organize key information, ensuring a thorough review. Consult with Medical Directors as needed to finalize resolutions.
- Maintain accurate records and compliance: Keep confidential documentation of complaints and grievances, respond promptly to health plan requests, and ensure all actions comply with health plan, state, and federal regulations.
- Review medical records for denied services: Evaluate prospective, concurrent, or past medical records using clinical guidelines to determine medical appropriateness, investigating member history, clinical background, benefits, and eligibility.
- Manage member transfer/termination requests: Track and process requests, prepare formal letters for patients and health plans documenting non-compliance or unacceptable behavior, and oversee the transfer/termination process.
- Support quality management (QM) projects: Assist in initiatives like HEDIS/Pay for Performance, clinical studies, and access surveys by compiling data and producing reports, charts, and graphs to highlight outcomes.
- Prepare and submit regulatory reports: Collect and submit required information for reports to regulatory agencies, health plans, and internal committees as directed by management.
- Conduct audits and ensure compliance: Schedule and perform medical record and facility site audits based on NCQA, CMS, DHS, and health plan standards. Develop corrective action plans, follow up on issues, and generate reports.
- Oversee credentialing and re-credentialing processes: Manage QM activities, ensuring required documentation (site reviews, medical record audits, study participation, and grievance outcomes) is submitted promptly to the Credentialing Oversight Coordinator/Provider Relations unit.
- Assist with health plan audits: Help prepare for audits by ensuring all documentation and processes meet requirements, working with management to implement necessary improvements.
MONICA
I've been blessed to touch so many lives through my serving. It's a privilege to uplift other employees with words of encouragement and a smile.
SOZIT
The first thing i noticed when i joined the team was how everyone is very welcoming and friendly with supportive management. I did not feel like an outsider.
EDGAR
Once I joined, I knew UCLA Health was THE place to be due to the growth potential and training offered
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