Clinical Policy Nurse RN II

L.A. Care Health Plan•Los Angeles, CA

About The Position

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.

Requirements

Associate's Degree in Nursing
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.
Registered Nurse (RN) - Active, current and unrestricted California License
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.

Nice To Haves

Bachelor's Degree in Nursing
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.
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.

Responsibilities

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.