Care Management Clinical Reviewer II
Los Angeles, CA, US, 90017
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
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. The position is also responsible for developing Compliance Department corrective action plans to address deficiencies identified by other departments conducting programmatic level audits. The position reports to the Care Management Services Director and collaborates with the Clinical Assurance, Medicare Operations, Compliance and other departments as needed to ensure Compliance and quality in Care Management operations.
Conducts monthly individual staff audits to measure individual level performance and compliance. Audits include regulatory, procedural and clinical components to be audited. Collaborates with CM leadership to implement and monitor individual CAPs and/or PIPs as necessary. Conducts administrative review of policies and procedures implemented by the CM department and by Vendors to comply with local, State, Federal and NCQA regulations, statues and guidelines. Ensure that besides complying with the laws and regulations, that specific functions and projects are carried out to achieve positive healthcare outcome for L.A. Care Membership. Responsible for the administrative review of policy and procedures using objective criteria for review and where policy nuances are utilized; peer to peer (auditor to auditor) consult is advised.
Coordinates and gathers documentation in order to respond to audits conducted either internally or externally.
Organize and perform file review process in accordance with given criteria to include collection & verification of supporting documentation, recording received information in appropriate tracking systems, and communicating end results of requests in writing and/or verbally.
Documentation and reporting of results to CM Leadership and other stakeholders as applicable.
Perform other duties as assigned.
Master's Degree in Health Administration
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.
Excellent verbal and written communication skills.
Excellent interpersonal skills.
Good working knowledge of regulatory requirements/standards.
Managed health care experience.
Proficiency with Microsoft (MS) Office Application, such as MS Word, Excel, and PowerPoint.
Ability to work independently.
Ability to solve complex issues and identify creative solutions.
Care Management Certification
Registered Nurse (RN) - Active, current and unrestricted California License
L.A. Care offers a wide range of benefits including
+ Paid Time Off (PTO)
+ Tuition Reimbursement
+ Retirement Plans
+ Medical, Dental and Vision
+ Wellness Program
+ Volunteer Time Off (VTO)