Utilization Management Clinical Quality Nurse Reviewer RN II

Salary Range:  $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
 

Job Summary

The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview of the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position focuses on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and creates reports on audit findings, as well as makes recommendations, to submit to the department's Quality Assurance Team and UM Management.

Duties

Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines.

Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions.

Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation. 

Works with department leadership to assess for all opportunities related to quality improvements. 

Compiles and presents quality report cards that measure adherence to quality and regulatory compliance. 

Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts.

Serves as a consultant to the organization's Compliance team on an ad hoc basis.

Performs other duties as assigned. 

Duties Continued

Education Required

Education Preferred

Experience

Required: 
At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation.  Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation.

Preferred:  
Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit.  Background in teaching and/or clinical education.

Skills

Required: 
Superior verbal and written communication skills. 

Advanced computer proficiency in both Microsoft Word and Excel. 

Strong analytical and team building skills. 

Ability to work independently and be self-directed. 

Ability to work effectively with diverse team members. 

Strong problem-solving skills. 

Ability to multitask and streamline day-to-day operations. 

Ability to translate regulatory requirements into auditable tools. 

Preferred:

Proven ability to lead successful performance improvement projects.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.  The range is subject to change.

L.A. Care offers a wide range of benefits including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)