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Clinical Assurance Compliance Nurse Specialist RN II
2 months ago
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: 11417 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. 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. 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. This position works closely with Regulatory Affairs and Compliance to ensure timely exchange of documentation to evidence compliance and is responsible for the internal auditing process for referral management and complex case management using approved auditing/monitoring tools. Duties Assist in the continual maintenance of Health Services Policies/Procedures, letter templates, workflows, audit tools, and training materials in compliance with regulatory requirements, new legislation, and accreditation standards. 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. Assist in the development and revisions of audit tools, policies, and provider trainings to improve compliance with regulatory and accreditation standards. Provide training, education, and consultation as necessary to delegates. Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Communicate to supervisors any barriers to completing assignments or daily work. Perform other duties as assigned. 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 and solve complex problems/issues. 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 Professional in Healthcare Quality (CPHQ) 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 #J-18808-Ljbffr
