Utilization Management Policy Initiatives Registered Nurse

The Utilization Management Policy Initiatives Nurse RN II, under the purview of 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. The position will curate clinical decision‑making resources, use data on clinical policies and authorizations to update prior authorization rules, define clinical paradigms for coding audit, and research and generate 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 rollout timeframes. The UM Policy Initiatives Nurse II will serve as a liaison to claims on developing clinical coding rubrics as well. The role will largely focus on policies and procedures related to Utilization Management for all lines of business. You will actively participate in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. The position performs literature review and analysis, creates summary reports for any findings of existing policy deficiencies, required changes based on new regulatory requirements to maintain compliance, and submits recommendations to the department’s Quality Assurance (QA) Manager and UM Senior Leadership. Job Summary The Utilization Management Policy Initiatives Nurse RN II is responsible for managing, reviewing, updating, and creating healthcare services clinical policies, guidelines, protocols, and related documentation, ensuring compliance with state and federal regulations, and supporting the overall utilization management mission. Job Duties Review, evaluate, and update existing healthcare services clinical policies to meet state regulatory and compliance requirements. Propose and present recommendations to improve existing clinical policies or develop internal policies when standard criteria are insufficient. Liaise with internal and external stakeholders to determine needs and goals of healthcare services clinical policies. Collaborate with certified coders to develop and ensure proper clinical coding documentation and policies. Gather, organize, and analyze data; identify market trends and conditions for upcoming clinical policy needs; present findings and action plans. Review literature to inform creation of new policies and produce summary reports. Perform final quality checks on all presentations, reports, or procedural documents related to healthcare services clinical policies, procedures, and desk job aids. Participate and lead specialty work groups related to clinical policies and procedures. Work closely with other health services and L.A. Care departments to disseminate reliable and accurate policies and procedures to all relevant stakeholders. Promote and support team engagements, programs, and activities that foster a positive and productive workplace environment. Assume ownership of projects from initial concept to implementation, under moderate guidance and supervision from UM leadership. Perform other duties as assigned. Required Education, Experience, Skills, Licenses/Certifications Active Registered Nurse (RN) unrestricted California License. Associate’s Degree in Nursing, Bachelor’s Degree in Nursing, Master’s Degree in Nursing, or related field. At least 8 years of clinical nursing experience. 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. Experience participating in state regulatory audits such as DHCS, DMHC, CMS, and/or NCQA audits. 1–2 years of experience editing and writing clinical health services policies. Proficiency in clinical policy development, literature searching, and evidence‑based research. 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 Microsoft Word and Excel, and PDF documentation. Ability to work effectively with diverse teams in cross‑functional work groups. Ability to multitask, re‑prioritize, and streamline day‑to‑day operations. High organizational and time‑management skills. Non‑Negotiable Requirements Direct past experience with healthcare/medical policy work specifically within a managed care plans environment, including the ongoing development of the medical policy review process and clinical and utilization data analysis. Experience developing training documents and presentations for new and/or revised medical policies to internal stakeholders. Active Registered Nurse (RN) unrestricted California License. Experience participating in DHCS/CMS/DMHC and NCQA audits. #J-18808-Ljbffr MDAEdge