Supervisor, Utilization Management Clinical Quality Nurse Reviewer RN
The Supervisor Utilization Management (UM) Clinical Quality Nurse RN, is responsible for executing the day-to-day operations as it relates to the monitoring the Clinical Quality Review nursing staff’s responsibilities and activities.
This includes, but not limited to, ensuring proper assignment and coverage of clinical auditing tasks, potential quality issue reviews; monitoring and evaluating functional team operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, functional team and departmental expectations; and conducting intermittent and annual performance evaluations.
This role assists in triaging identified issues/problems as they related to Clinical Audits and forming resolution within the scope of work/licensure. The Supervisor supports regulations, policies, protocols, and procedures of the department.
Associate's Degree in Nursing
Bachelor's Degree in Nursing
Master's Degree in Nursing
5-7 years of experience in Clinical Nursing with a minimum of 2 years of auditing clinical documentation. 3-4 years experience as a lead in a program/ process/, staff or supervisory experience.
Active participation in at least two state regulatory audits and one federal regulatory audits.
Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation.
Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one NCQA audit and/or CMS audit.
Background in teaching and/or clinical education.
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.