Clinical Assurance Compliance Nurse Specialist RN II

Job Category:  Clinical
Department:  Clinical Assurance
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  5072

 

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 in five health plans, we make sure our members get the right care at the right place at the right time.

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 and to support the safety net required to achieve that purpose.

Job Summary

The Clinical Assurance Compliance Nurse Specialist, RN II is responsible for the review of regulatory, contractual and accreditation standards to ensure Health Care Services Department policies are in compliance and in operation. The position works closely with Regulatory Affairs and Compliance to ensure timely exchange of documentation to evidence compliance. The position is responsible for the internal auditing process for referral management and complex case management using approved auditing/monitoring tools. This position participates in the review and presentation when necessary of training materials for external delegates and internal staff training. 

Duties

Assist in the continual maintenance of Health Services Policies/Procedures, letter templates, Workflows, Process, Audit Tools and Training Materials in compliance with regulatory requirements, new legislation and accreditation standards. Assists in the develop of an revisions to Policies/Procedures. Works collaboratively with Regulatory Affairs & Compliance to ensure Health Services Departments are made aware and department documents updated accordingly.

 

Develops and maintains Medical Management training materials in compliance with all regulatory requirements, new legislation, and accreditation standards. Assist in the preparation of the Health Services Departments for review by external regulatory and accrediting bodies (Department of Health Care Services (DHCS), A&I, DHCS Member Rights, Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services(CMS)) and internally for audits by RAC through team processes. 

 

Assist in the development and revisions of audit tools, Policies, provider trainings to improve compliance with regulatory and accreditation standards. Develop and implement procedures to assurance compliance with care coordination and documentation of Utilization Management (UM) and CM element.

 

Provide training, education and consultation as necessary to delegates. Collaborate with other UM staff on identifying topics and developing agendas for the JOMs/performance visits/communications. 

 

Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assist co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions.   

 

Communicates to supervisors any barriers to completing assignments or daily work with delegates in an efficient and effective manner. Demonstrates reliability and good attendance and punctuality standards. 

 

Perform other duties as assigned. 

Education Required
Associate's Degree in Nursing
Education Preferred
Bachelor's Degree in Nursing
Experience

Required:
At least 5-7 years experience in a clinical setting and in a managed care plan performing UM oversight, including auditing.

 

Good working knowledge of licensure and regulatory requirements, and accreditation standards; Managed Health Care experience.

 

Knowledge of issues pertaining to Medi-Cal, Medicare, and other HMO & IPA contracts & payers.

Skills

Required:
Ability to manage and organize large volumes of data; Knowledge of regulatory and accreditation entities and their requirements.

 

Excellent verbal and written communication skills; excellent interpersonal skills.

 

Proficient in MS Office applications.

 

Ability to work independently.

 

Ability to solve complex problems/issues and identify creative solutions.

Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Licenses/Certifications Preferred
Certified Professional in Utilization Review (CPUR)
Certified Case Manager (CCM)
Certified Professional in Healthcare Quality (CPHQ)
Required Training
Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)


Nearest Major Market: Los Angeles

Job Segment: Nursing, Clinic, Medical, Registered Nurse, Medicare, Healthcare