Salary: $111,656.88 - $167,136.48 Annually
Location: Los Angeles County, CA
Job Type: Full time
Job Number: Y5125L
Department: HEALTH SERVICES
Opening Date: 05/21/2025
Exam Number: Y5125L
Type of Recruitment: We welcome applications from anyone!
Application Filing Period: Begins on May 22, 2025, at 9:00 a.m. (PT) Continuous. Applications will be accepted until the position is filled.
Why Join the LA County Department of Health Services?
The Los Angeles County Department of Health Services (DHS) is a cornerstone of our community's health. As the second largest municipal health system in the nation, DHS operates an integrated network of 25 health centers and four hospitals, alongside an expanded network of community partner clinics. Every year, we deliver compassionate, life-saving care to over 600,000 unique patients across LA County. With more than 23,000 dedicated staff members and an annual budget exceeding $6.9 billion, DHS is dedicated to transforming healthcare and creating lasting change in our community.
For additional information regarding DHS, please visit www.dhs.lacounty.gov
Check Out Our Outstanding Benefits!
We offer one of the strongest public-sector benefits packages in the country. Join us and discover a rich selection of health care options, robust retirement plans, and the flexibility to work, relax and rejuvenate as you reach your fullest personal and professional potential.
Click here to see comprehensive information regarding County employee benefits.
DHS is seeking dedicated Utilization Review Nurse Supervisors to join our team. Whether you're working in community clinics or hospitals, this is your opportunity to grow your career while serving diverse communities across LA County.
Definition: Provides technical and administrative direction to staff performing reviews of patients' medical charts to ascertain the medical necessity for services and the appropriateness of the level of care.
Essential Job Functions:
Plans, directs, assigns, and evaluates the work of subordinates engaged in utilization review activities. Plans, develops, and implements procedures to fulfill the requirements and guidelines for an effective and timely utilization review system. Confers with physicians, administrative personnel, and other disciplines in the hospital to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures. Determines need for and conducts in-service training to improve quality of admission and continued stay reviews, and to disseminate information concerning new or revised procedures. Works with Professional Standards Review Organization representative to orient new staff to Federal laws and regulations pertaining to Medicare and Medi-Cal reimbursement. Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for the referral of unusual questionable cases, on referred cases for reconsideration, and to obtain authorization for the issuance of denial letters. Reviews, retrospectively, utilization review records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information. Develops procedures for the compilation of information from medical charts concerning particular diagnoses, problems, procedures, or practitioner categories as directed for medical care evaluation studies. Prepares and analyzes reports on number and status of reviews, physician advisor referrals, and type of physician advisor determinations to determine if improvement in procedures or additional staff training is needed, and to make recommendations on potential areas for medical care evaluation studies. Attends Utilization Review Committee meetings to inform the committee of new or revised utilization review requirements, the impact of the requirements, and procedures to be implemented for compliance, as needed.
As a unit supervisor at the LA General Medical Center:
Has immediate responsibility for organizing, assigning, and evaluating the work of at least seven Utilization Review Nurses. Acts as a technical resource person to subordinate staff concerning Federal regulations pertaining to Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards. Participates in the formulation of and changes in utilization review procedures by assessing the effectiveness of the review system and providing information on the policies and procedures within the assigned medical areas. Provides input for the in-service training program by identifying areas of deficiency in staff knowledge or experience. Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for follow up on referrals. Reviews, retrospectively, Utilization Review Records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information. Compiles data on number and status of reviews, physician advisor referrals, and type of physician advisor determinations. Maintains effective working relationships with unit physicians to facilitate the execution of the utilization review system. Participates in the work performed by subordinates.
Selection Requirements:
Option I: One year of experience performing the duties of a Utilization Review Nurse or Medical Service Coordinator, CCS. -OR- Option II: Two (2) years of experience as a registered nurse, of which one year must be in the treatment of chronic and short-term medical and surgical inpatient problems, AND one (1) year of experience in the first-level supervision of registered nurses and other nursing staff.
License Requirement Information:
A current, active license to practice as a Registered Nurse issued by the California Board of Registered Nursing. A current Basic Life Support (BLS) for Healthcare Providers (CPR & AED) Program certification issued by the American Heart Association.
Applicants must ensure the Certificates and Licenses Section of the application is completed. Provide the title(s) of your required certification(s) and/or license(s), the number(s), date(s) of issue, date(s) of expiration, and the name(s) of the issuing agency for the required certification(s) and license(s) specified above. Required certificates and licenses has to be active and unrestricted, or your application will not be accepted. Applicants must attach a legible copy/image of required and/or desired certifications and licenses to their application at the time of filing, or email the document/s to the exam analyst to aharraway@dhs.lacounty.gov (gmargosian@dhs.lacounty.gov) within seven (7) calendar days from the application date. Applications submitted without the required certificates and/or licenses will be rejected. Applicants claiming experience in a state other than California have to provide their Registered Nurse license number from that state on the application at the time of filing. Out-of-State experience provided on the application without the required license number will not be considered.
Physical Class: Physical Class II Light: This class includes administrative and clerical positions requiring light physical effort that may include occasional light lifting to a 10-pound limit and some bending, stooping, or squatting. Considerable ambulation may be involved.
Special Requirements Information:
An Utilization Review Nurse is an RN that has Case Management experience whose primary charge is to ensure that the care provided to patients are appropriate and covered by the insurance payer. They are responsible for ensuring that patient services are cost-effective, and their stay is at the appropriate level of care and length of stay. In the County of Los Angeles, a Medical Service Coordinator, CCS determines medical eligibility of children referred to California Children Services and approves and coordinates treatment services for children accepted under the program. Supervision MUST include all the following: planning, assigning, reviewing work of staff and formally evaluating employee performance.
To receive credit for your education, include a copy of your official diploma, official transcript, or letter/certificate from an accredited institution with your application at the time of filing or within seven (7) calendar days of filing your application. The document should show the date the degree was conferred and be in English; if it is in a foreign language, it must be translated and evaluated for equivalency to U.S. standards. For more information on our standards for educational documents, please visit: https://file.lacounty.gov/SDSInter/dhr/070812_PPG123.pdf and https://file.lacounty.gov/SDSInter/dhr/205105_PPG_123_ACE_Resource_Guide.pdf. Please submit documentation to aharraway@dhs.lacounty.gov (gmargosian@dhs.lacounty.gov) and indicate your name, the exam name, and the exam number. We do not accept password-protected documents. Ensure documents are unlocked before attaching to your application or sending to the exam analyst.
Desirable Qualifications:
Additional credit will be given to applicants who possess the following desirable qualifications in excess