L.A. Care Health Plan
Utilization Management Clinical Quality Nurse Reviewer RN II
L.A. Care Health Plan, Los Angeles, California, United States, 90079
Utilization Management Clinical Quality Nurse Reviewer RN IIJob Category: Clinical
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID: 11397
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.
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.
Job SummaryThe Utilization Management Clinical Quality Nurse Reviewer RN II 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 serves as a Subject Matter Expert during external audits and 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.
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 to quality and accuracy of case documentation.
Works with department leadership to assess 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 potential risks, collaborating 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.
Education RequiredAssociate's Degree in Nursing
Education Preferred
Bachelor's Degree
Master's Degree in Nursing
ExperienceRequired: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 audit. Previous experience with Medi-Cal and Medicare in a managed care environment.
Preferred:Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one NCQA audit and/or CMS audit.
SkillsRequired:Superior verbal and written communication skills. Advanced computer proficiency in Microsoft Word and Excel. Strong analytical and team-building skills. Ability to work independently and be self-directed. Strong problem-solving skills.
Preferred:Proven ability to lead successful performance improvement projects.
Licenses/Certifications RequiredRegistered Nurse (RN) - Active, current and unrestricted California License
Physical RequirementsLight
Additional InformationSalary 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
Nearest Major Market:
Los Angeles
#J-18808-Ljbffr
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID: 11397
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.
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.
Job SummaryThe Utilization Management Clinical Quality Nurse Reviewer RN II 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 serves as a Subject Matter Expert during external audits and 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.
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 to quality and accuracy of case documentation.
Works with department leadership to assess 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 potential risks, collaborating 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.
Education RequiredAssociate's Degree in Nursing
Education Preferred
Bachelor's Degree
Master's Degree in Nursing
ExperienceRequired: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 audit. Previous experience with Medi-Cal and Medicare in a managed care environment.
Preferred:Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one NCQA audit and/or CMS audit.
SkillsRequired:Superior verbal and written communication skills. Advanced computer proficiency in Microsoft Word and Excel. Strong analytical and team-building skills. Ability to work independently and be self-directed. Strong problem-solving skills.
Preferred:Proven ability to lead successful performance improvement projects.
Licenses/Certifications RequiredRegistered Nurse (RN) - Active, current and unrestricted California License
Physical RequirementsLight
Additional InformationSalary 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
Nearest Major Market:
Los Angeles
#J-18808-Ljbffr