The Utilization Management Policy Initiatives Nurse RN II, under the purview the Utilization Management (UM) Department Leadership Team, 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. This position will be responsible for curating our clinical decision making resources, using data on clinical polices and authorizations to update our prior authorization rules, defining clinical paradigms for coding audit and researching and generating guidelines when current resources are incomplete. This position will work cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The UM Policy Initiatives Nurse II will serve as a liaison to claims on developing clinical coding rubrics as well.
This position will largely focus of policies and procedures related to Utilization Management for all lines of business. Actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position performs literature review and analysis and creates summary reports for any findings of existing policy deficiencies, required changes based on new regulatory requirements to maintain compliance, as well as make recommendations, to submit to the department's Quality Assurance (QA) Manager and UM Senior Leadership.
Review, evaluate existing Healthcare Services clinical policies due for review as needed to meet state regulatory and compliance requirements.
Propose and presents recommendations to improve existing clinical policies to meet new requirements and develop internal policies when standard criteria is not sufficient for decision making. Edit or amend existing and new policy drafts, including assistance with final quality checks to ready for approval for quarterly Utilization Management Committee meetings.
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. Develop health policies by analyzing statistical data. Identify and analyze data for market trends and conditions for upcoming clinical policy needs. Presents results and recommendations with subsequent action plans as necessary.
Gather and review all necessary literature to inform creation of new healthcare services policies., and to produce summary reports related to any clinical policy updates needed.
Performs 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 of our 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.
Perform other duties as assigned.
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.