Clinical Policy Nurse RN II

Job Description

The Clinical Policy Nurse RN II is responsible for analytical research, trending, and assessment based on legislation, regulatory and accreditation requirements that impact claims, Utilization Management (UM) department and healthcare services policies.

Reviews and analyzes clinical financial data to assess the effectiveness of existing and proposed policies to identify opportunities for improvement, cost containment, and quality enhancement.

This position plays a key role in translating regulatory impacts into operational strategies and works collaboratively with internal and external stakeholders to ensure clinical policies support safe, effective, and compliant care delivery. Assists in development of policies and programs that improve health outcomes and target Fraud, Waste and Abuse (FWA).

This position works cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The Clinical Policy Nurse II serves as a liaison to ensure the ongoing maintenance of clinical coding for the authorization matrix.

Qualifications

Education Required:

• Associate's Degree in Nursing

Preferred:

• Bachelor's Degree in Nursing

Experience Required:

• At least 5 years of experience in Clinical Nursing.At least 3 years of 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.

Preferred: 

• 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. 
• At least 1 year of experience in clinical health services policies with a managed care plan. 

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.