Nursing Jobs in Rossmoor, CA
$88,854 - $142,166 / year
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 Clinical Policy Nurse RN II is responsible for analytical research, trending, and assessment based on legislation, regulatory and accreditation requirements that impact claims, Utilization Management (UM) department and healthcare services policies. Reviews and analyzes clinical financial data to assess the effectiveness of existing and proposed policies to identify opportunities for improvement, cost containment, and quality enhancement. This position plays a key role in translating regulatory impacts into operational strategies and works collaboratively with internal and external stakeholders to ensure clinical policies support safe, effective, and compliant care delivery. Assists in development of policies and programs that improve health outcomes and target Fraud, Waste and Abuse (FWA). This position works cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The Clinical Policy Nurse II serves as a liaison to ensure the ongoing maintenance of clinical coding for the authorization matrix. Duties Assess federal, state, and local legislation, regulatory guidance, and health care policies to identify potential impacts on clinical practice, reimbursement and organizational operations that impact healthcare services policies. Review and interpret clinical, utilization, and financial data to identify trends, opportunities for policy improvement and cost-savings. Research, develop, and evaluate clinical and health policy designed to improve patient outcomes, detect and mitigate Fraud, Waste, and Abuse (FWA), and streamline organizational processes. Monitor the implementation of health programs, clinical initiatives, and community action plans to assess effectiveness, compliance, and impact on patient outcomes. Collaborate with internal stakeholders to evaluate utilization trends and anomalies and contribute to policy development aimed at improving efficiency and compliance identified during risk assessments. Prepare analytical reports, summaries, and analyses assessing policy performance, regulatory impact, and communicate insights and recommendations to stakeholders to drive evidence-based policy and impacted outcomes. Present findings, recommendations, and action plans to key stakeholders. Participate in work groups related to healthcare services clinical policies and procedures including efforts to improve department processes, as needed. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with active participation in state regulatory audits such as Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and/or National Committee for Quality Assurance (NCQA) audits. At least 1 year of experience in clinical health services policies with a managed care plan. Skills Required: Demonstrated strong reporting skills by preparing clear, concise reports and presentations that communicate findings and performance. Working knowledge of clinical policies. Strong analytical and critical thinking skills with the ability to interpret regulatory requirements and legislation. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong problem solving and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Understanding of the managed care industry and market conditions. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light 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) 
$88,854 - $142,166 / year
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 Delegation Oversight Clinical Auditor RN II is responsible for ensuring that delegates contracted to perform Utilization Management (UM) functions on behalf of L.A. Care (LAC) is in compliance with all UM regulatory requirements and new legislation through the maintenance of required policies/procedures/workflows/ processes/audit tools necessary to meet the requirements. This position utilizes a rapid team approach for needed improvements identified through external audits of delegated entities. This position assist in maintaining continuous quality improvement in the Delegation Oversight Clinical Audit unit ensuring that departmental/divisional and organizational goals are accomplished through overseeing and facilitating compliance of the Plan Partners, Participating Provider Groups (PPG), Specialty Health Plans (SHP), and contracted provider network as managed by the Delegation Oversight Department. This position is responsible, as part of the oversight team, for ensuring compliance of the Plan Partners and/or Participating Physician Groups (PPG) to regulatory, contractual and L.A. Care requirements. This position is responsible for performing annual and focused audits. This position also acts as a liaison between the Plan Partners and PPGs and L.A. Care Health Plan regarding UM issues. The position assists in improving access and utilization performance of Plan Partners and PPGs by being a resource for best practices and providing continuous feedback. Additionally, the oversight responsibility of this position includes reporting to management and providing consultation/instructional/coaching recommendations to improve overall compliance of Plan Partners and PPGs with all regulations and standards. Duties Continually ensures delegate compliance with UM Policies/Procedures, Letter Templates, Workflows, Processes, and Audit Tools in compliance with all regulatory requirements/new legislation. Works collaboratively with Regulatory Affairs & Compliance. Stay abreast of new UM legislation, regulations, or other changes impacting UM in order to put processes in place for compliance. Prepares the Delegation Oversight Clinical Audit team for internal audits and for conducting PP/PPG audits, developing mechanisms for tracking/ trending of progress for --UM/PPG (internal) and PP (external) for compliance with UM standards, and identities system/individual areas for improvement through these processes. Prepares the Delegation Oversight Department for review by external regulatory bodies. Ensures that the Delegation Oversight Department is continually prepared for external review with staff daily work conducted in a manner that meets regulatory requirements. Ensures that the Delegation Oversight Clinical Audit unit functions as a team in preparing needed documents for an external review. Completes annual, focused and periodic audit activities timely and thoroughly including identification of deficiencies, response to mitigation, review and response to CAPs. Identifies repeat deficiencies. Assures audit documentation is clear, complete and accurate. Completes periodic monitoring of PP or PPG performance in critical deficiency areas. Completes follow-up audits and related reports and recommendations. Identifies options to assist PP or PPGs with continued or significant deficiencies. Updates audit tools to meet regulatory, contractual and L.A. Care requirements. Develops and conducts ongoing monitoring activities including but not limited to file reviews and letters and supplemental reports. Present summary results to L.A. Care's UM Committee. Communicates with assigned PP and PPGs on an ongoing basis. Develop mechanism to track and trend progress of PP and PPG's compliance to UM standards and identify system wide issues. Maintains confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assists co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions. Actively identifies and makes recommendations to supervisor ideas to improve the quality effectiveness and efficiency of departmental and health services functions. Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner. Duties Continued Provides training, education and consultation as necessary to PP and PPGs. Collaborates with other Clinical Auditors on identifying topics and developing agendas for the JOM's and PP visits/communication. Develops and implements procedures to assure compliance with care coordination and documentation of linked and carved out services. Conducts Interrater Reliability Testing (referral management and oversight) for new staff/physicians and annually or as needed for existing staff/physicians. Works with other departments as necessary to facilitate teamwork for creating and/or improving interdepartmental processes to meet regulatory requirements. Clinical Auditor (Performance Monitoring): In addition to the responsibilities above, the Clinical Auditor (Performance Monitoring) position ensures compliance of the delegates (Participating Physician Groups, Plan Partners and Vendors) with regulatory, contractual and L.A. Care business requirements. This position is responsible for delegation oversight continuous monitoring activities and monitoring corrective action plans from the annual and focused audits. The position also acts as a liaison between the Plan Partners, PPGs and Vendors regarding Utilization Management (UM) issues; assists in improving access and utilization performance of PPGs by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility of this position includes attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards. Clinical Auditor (Behavioral Health): In addition to the duties above, the Clinical Auditor (Behavioral Health) designs an audit program specific to ensuring delegates are meeting behavioral health regulatory requirements. This ensures Specialty Health Plans and Plan Partners are in compliance with regulatory, contractual, and L.A. Care business requirements. This position is responsible for developing and maintaining annual audit tools, policy requirements specific to delegates, and a monitoring program to continually receive and aggregate Behavioral Health specific performance requirements. The position acts as a liaison between Specialty Health Plans and Plan Partners regarding Behavioral Health issues, assists in improving access and Behavioral Health performance by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility includes liasing with internal Behavioral Health units, the Medical Director of Behavioral Health, attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards. Performs other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 7 years in a clinical setting with at least 3 years in a managed care setting in Utilization Management/Case Management. Skills Required: Knowledge of issues pertaining to Medi-Cal and other HMO & IPA contracts, & payers. Ability to manage and organize large volumes of data. Knowledge of accreditation entities and their requirements. Excellent verbal and written communication skills and excellent interpersonal skills. Good working knowledge of regulatory requirements/standards. Ability to work independently. Ability to solve complex issues and identify creative solutions. Computer ease & literacy with Word, Excel, PowerPoint Skills. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light 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) 
