Remote - Utilization Management Policy Initiatives Nurse II

Title - Utilization Management Policy Initiatives Nurse II

Job Type - Permanent | Onsite | Remote | Hybrid (Role will be expected to work PST hours; candidate can live outside of California (but they must have a CA RN license).

Location - Los Angeles, CA

Shift - All Shifts Available

Job Summary :

The Utilization Management Policy Initiatives Nurse RN II, under the purview the Utilization Management (UM) Department Leadership Team, is responsible for managing, reviewing, updating and creating Healthcare Services clinical policies, guidelines, protocols and related documentation.

This role ensures that the day to day functions of Utilization Management initiatives comply with regulatory and accreditation requirements such as those stated in contracts, CalAIM Population Health Management (PHM) Policy Guide, National Committee on Quality Assurance (NCQA) Department of Health Care Services (DHCS) All Plan Letters (APLs), and Centers for Medicare and Medicaid Services (CMS) Model of Care (MOC) through sound clinical policy maintenance. This position will be responsible for curating our clinical decision making resources, using data on clinical polices and authorizations to update our prior authorization rules, defining clinical paradigms for coding audit and researching and generating guidelines when current resources are incomplete. This position will work cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The UM Policy Initiatives Nurse II will serve as a liaison to claims on developing clinical coding rubrics as well.

This position will largely focus of policies and procedures related to Utilization Management for all lines of business. Actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position performs literature review and analysis and creates summary reports for any findings of existing policy deficiencies, required changes based on new regulatory requirements to maintain compliance, as well as make recommendations, to submit to the department's Quality Assurance (QA) Manager and UM Senior Leadership.

Duties :

• Review, evaluate existing Healthcare Services clinical policies due for review as needed to meet state regulatory and compliance requirements.
• Propose and presents recommendations to improve existing clinical policies to meet new requirements and develop internal policies when standard criteria is not sufficient for decision making. Edit or amend existing and new policy drafts, including assistance with final quality checks to ready for approval for quarterly Utilization Management Committee meetings.
• Liaise with internal and external stakeholders to determine needs and goals of existing healthcare services clinical policies.
• Collaborate with certified coders to develop and ensure proper clinical coding documention and policies.
• Gather, organize, and analyze information. Develop health policies by analyzing statistical data. Identify and analyze data for market trends and conditions for upcoming clinical policy needs. Presents results and recommendations with subsequent action plans as necessary.
• Gather and review all necessary literature to inform creation of new healthcare services policies., and to produce summary reports related to any clinical policy updates needed.
• Performs final quality checks on all presentations, reports or procedural documents related to Healthcare Services clinical policies, procedures and desk job aids.
• Participate and lead in specialty work groups related to healthcare services clinical policies and procedures including efforts to improve department processes, as needed.
• Works closely with other Health Services departments as well as other L.A. Care departments to ensure dissemination of reliable and accurate policies and procedures to all relevant stakeholders.
• Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.
• Assume ownership under direction of the department leadership, for successful development, planning, and execution of projects, from initial concept to implementation stage, with moderate guidance and supervision from the UM leadership team.
• Perform other duties as assigned.

Education Required

Experience Required :