Utilization Management Clinical Quality Nurse Reviewer RN II

The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role is 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 development and review of policies and procedures to certify compliance with regulatory guidelines and mandates.This position will focus 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 create reports on audit findings, as well as make recommendations, to submit to the department's Quality Assurance Team and UM Management.

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