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.
The UM Denial Nurse Reviewer supports high-quality, cost-effective care by applying clinical knowledge, policies, and regulatory guidelines to the review and processing of adverse organization determinations. This role reviews denials for appropriate clinical documentation and criteria, provides clinical guidance on denial cases, and ensures written notifications are accurate, understandable, timely, and compliant with policies and applicable regulatory requirements.
Key Responsibilities:
- Review and process denials for appropriate clinical documentation, clinical criteria/guidelines, benefit policies, and regulatory compliance.
- Apply clinical knowledge and the appropriate clinical review hierarchy when evaluating denial cases and written notifications.
- Collaborate with Denial Coordinators, Prior Authorization teams, Medical Directors, and department leadership to clarify cases and support appropriate denial determinations.
- Monitor denial processing and turnaround times to ensure regulatory standards and guidelines are met.
- Review denial letters for clear, understandable language and compliance with applicable requirements.
- Identify trends in denial types and outcomes and support process improvement initiatives.
- Develop and analyze denial activity and outcome reports to identify opportunities for improvement.
- Current CA LVN licensure required
- Two or more years of utilization review/utilization management experience in an HMO, MSO, IPA, or health plan environment
- Previous clinical experience
- Experience drafting and issuing compliant adverse organization determinations
- In-depth knowledge of health plan, DMHC, CMS, HIPPA, and NCQA requirements
- Expertise in abstracting and interpreting medical information from patient records
- Strong communication, interpersonal, analytical, problem-solving, organizational, and prioritizing skills
- Thorough understanding of the Hierarchy of Clinical Criteria
- Experience with Flesch-Kincaid readability scoring
- Knowledge of the appeals process
- Experience with audit preparation
- Basic computer skills
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UCLA Health Recruitment is currently being targeted by scam artists through external job board sites. Review some tips in order to avoid becoming targeted. El reclutamiento de salud de UCLA actualmente está siendo atacado por estafadores a través de sitios de juntas de trabajo externos. Revisar algunos consejos para evitar ser apuntado.
“The environment is nurturing and fosters growth. When I come to work, I know what I'm doing matters.”
VINCENT, Sr. CLS Specialist, Toxicology
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
RENE
If you want to grow professionally, this is the right place for you.
ERA
We are family here. We support each other. We collect together.
ELIZABETH
It’s so diverse and inclusive here. There’s always the opportunity to share your thoughts. It's a place where you feel you belong.
JERRY
Your career path at UCLA Health will enable you to follow a myriad of avenues and turns. It opens up a wide variety of opportunities.
ORLANDO
There’s a togetherness and higher level of commitment to teamwork at UCLA Health. We are several groups and teams that work together with a common goal which is to improve our patients experience.
KATHERINE
UCLA Health is a supportive, collaborative, and purposeful environment where leadership is invested in your growth and creating real opportunities. And knowing that what we do matters gives a real sense of purpose.
DR. ISLA GARRAWAY
UCLA has incredible resources and a team science approach. The ability to work with collaborative teams and access the amazing resources around campus is the best part about being at UCLA.
RADU
UCLA is very diverse in its personnel as well as its many research fields studied
JENNA
UCLA Health provides so many opportunities to exchange ideas, share moments and grow. I have learned a lot about team management and relationship building.
SHARON
I was looking for a job to further my career and continue to improve and learn as a therapist.
TARO
I have been blessed to be surrounded by supportive colleagues who aspire me to be the best version of myself.
Awards & recognition
