The Care Management Clinical Reviewer II is responsible for supporting the Care Management (CM) team. This includes monthly individual staff audits (or more frequent per business need), administrative review of policies and procedures for Care Management, Specialty Health Plan/Vendors, Plan Partners, and other entities, if necessary, to ensure compliance with local, State, Federal and National Committee on Quality Assurance (NCQA) regulations, statues and guidelines. The position also contributes toward administrative file reviews/audits and program descriptions. The position is responsible for preparing the individual staff audit findings, documentation of deficiencies as well as developing final staff reports for the Care Management Department Directors and supervisors of the audited resources.

Qualifications

• Master's Degree in Health Administration or Related Field
• Bachelor's Degree in Nursing
• At least 3 years of experience in documentation, reporting, and auditing in a healthcare or managed care environment.
• Care Management experience in a managed care setting. 
• Experience with Centers for Medicare and Medicaid Services (CMS) and California Department of Health Care Services (also called the State) (DHCS) regulatory requirements and NCQA. 

About the Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.