Utilization Management Clinical Quality Nurse Reviewer RN II

L.A. Care; Los Angeles (CA); On-site; USD 89,000 - 142,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Job summary

L.A. Care Health Plan in California is seeking an Utilization Management Clinical Quality Nurse Reviewer RN II to lead audits, ensure regulatory compliance, and support external audits.

This role focuses on UM cases across lines of business to improve audit outcomes and service quality. The position requires an Associate's Degree in Nursing, California RN license, and 5+ years in clinical nursing with auditing experience; preferred Bachelor's or Master’s in Nursing, and strong communication and

Qualifications

• Requires RN license in California.
• At least 5 years of clinical nursing experience.
• Minimum 2 years of auditing clinical documentation.
• Experience with Medi-Cal and Medicare in a managed care environment.
• Active participation in regulatory audits (state and federal).
• Strong communication and analytical skills.

Responsibilities

• Audit and track internal department documentation.
• Lead pre- and post-audit preparation and follow-up.
• Develop and review policies to ensure regulatory compliance.
• Identify opportunities to improve audit outcomes and service quality.
• Present quality metrics and risk assessments to leadership.
• Collaborate with Compliance and QA teams on audits.

Skills

Verbal and written communication

Analytical thinking

Team building

Independent work

Multitasking

Regulatory translation

Education

Associate's Degree in Nursing

Bachelor's Degree

Master's Degree in Nursing

Tools

Microsoft Word

Excel

Job description

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Utilization Management Clinical Quality Nurse Reviewer RN II

Job Category: Clinical

Location: ID, US

Position Type: Full Time

Requisition ID: 13392

Salary Range:$88,854.00(Min.) -$115,509.00(Mid.) -$142,166.00(Max.)

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, 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 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.

Duties

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.

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.

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.

Skills

Required:
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.

Preferred:

Proven ability to lead successful performance improvement projects.

Licenses/Certifications Required

Registered Nurse (RN) - Active, current and unrestricted California License

Licenses/Certifications Preferred

Required Training

Physical Requirements

Light

Additional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offersa wide range of benefits including

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