Utilization Management Clinical Quality Nurse Reviewer RN II

L.A. Care Health Plan•Los Angeles, CA

36d

About The Position

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.

Requirements

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

Nice To Haves

Bachelor's Degree
Master's Degree in Nursing
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.
Proven ability to lead successful performance improvement projects.

Responsibilities

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.