Clinical Policy Initiatives Registered Nurse
6 days ago
The Utilization Management Policy Initiatives Registered Nurse 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.
Key Responsibilities- Review, evaluate, and update existing Healthcare Services clinical policies to meet state regulatory and compliance requirements.
- Propose and present recommendations to improve existing clinical policies to meet new requirements and develop internal policies when standard criteria are not sufficient for decision making.
- 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 documentation and policies.
- Gather, organize, and analyze information to develop health policies by analyzing statistical data.
- Presents results and recommendations with subsequent action plans as necessary.
- Perform 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.
- Active Registered Nurse (RN) unrestricted California License.
- Associate's Degree in Nursing while Bachelor's Degree in Nursing or Master's Degree in Nursing or Related Field.
- At least 8 years of previous experience in Clinical Nursing.
- At least 3 years of previous experience with Medi-Cal and Medicare in a managed care environment.
- Experience in performing and creating clinical documentation.
- Experience in regulatory compliance for a health plan.
- Experience with active participation in state regulatory audits such as Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and/or National Committee for Quality Assurance (NCQA) audits.
- 1-2 years of experience in editing and writing clinical health services policies with a managed care plan.
- Proficiency in clinical policy through skills in literature searching and clinical research analysis based on the best available evidence.
- Working knowledge of clinical policies.
- Ability to translate regulatory requirements into auditable tools.
- Ability to perform independent research on complex medical topics.
- Superior verbal and written communication skills.
- Strong analytical, problem-solving, and team-building skills.
- Ability to work independently and be self-directed.
- Advanced computer proficiency in both Microsoft Word and Excel, as well as PDF documentation.
- Ability to work effectively with diverse teams in cross-functional work groups.
- Ability to multitask, re-prioritize tasking, and streamline day-to-day operations.
- Highly proficient in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence.
- Understanding of the managed care industry and market conditions.
- High organizational and time-management skills.
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