Job Description

Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented Team.

Job Title: Utilization Review Nurse

Location(s): Los Angeles, CA

Job Description:

• 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.

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.

Shift:

• Day 5x8-Hour (08:00 - 17:00)

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.

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