Experience Inc. Jobs

Clinical Assurance Compliance Nurse Specialist RN II

Job Category: Clinical

Department: Enterprise Performance Optimization

Location:

Los Angeles, CA, US, 90017

Position Type: Full Time

Requisition ID: 11416

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 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. Work collaboratively with Regulatory Affairs & Compliance to ensure Health Services Departments are made aware and department documents updated accordingly. Develop and maintain 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 Real Application Clusters (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 identify and implement efforts to improve the quality, effectiveness and efficiency of job functions. Communicate to supervisors any barriers to completing assignments or daily work with delegates in an efficient and effective manner. Demonstrate reliability and good attendance and punctuality standards.

Perform other duties as assigned.

Duties Continued

Education Required

Associate's Degree in Nursing

Education Preferred

Bachelor's Degree in Nursing

Experience

Required:

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

Managed Health Care experience.

Skills

Required:

Good working knowledge of licensure and regulatory requirements, and accreditation standards.

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.

Knowledge of issues pertaining to Medi-Cal, Medicare, and other Health Maintenance Organization (HMO) & Independent Practice Association (IPA) contracts and payers.

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

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 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)