Job Description

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.

Qualifications

Education Required:

• Associate's Degree in Nursing

Education Preferred:

• Bachelor's Degree
• Master's Degree in Nursing

Experience Required:

• 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.

Experience Preferred:

• 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.

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