The Clinical Assurance Compliance Nurse Specialist, RN is responsible for the review of regulatory, contractual and accreditation standards to ensure Health Care Services Department policies are in compliance and in operation. The position works closely with Regulatory Affairs and Compliance to ensure timely exchange of documentation to evidence compliance. The position is responsible for the internal auditing process for referral management and complex case management using approved auditing/monitoring tools. The Clinical Assurance Compliance Nurse Specialist, RN participates in the review and presentation when necessary of training materials for external delegates and internal staff training.
Assist in the continual maintenance of Health Services Policies/Procedures, letter templates, Workflows, Process, Audit Tools and Training Materials in compliance with regulatory requirements, new legislation and accreditation standards. Assists in the develop of an revisions to Policies/Procedures. Works collaboratively with Regulatory Affairs & Compliance to ensure Health Services Departments are made aware and department documents updated accordingly.
Develops and maintains Medical Management training materials in compliance with all regulatory requirements, new legislation, and accreditation standards. Assist in the preparation of the Health Services Departments for review by external regulatory and accrediting bodies (DHCS, A&I, DHCS Member Rights, DMHC, NCQA and CMS) and internally for audits by RAC through team processes.
Assist in the development and revisions of audit tools, Policies, provider trainings to improve compliance with regulatory and accreditation standards. Develop and implement procedures to assurance compliance with care coordination and documentation of UM and CM element.
Provide training, education and consultation as necessary to delegates. Collaborate with other UM staff on identifying topics and developing agendas for the JOMs/performance visits/communications.
Maintain confidentiality in compliance with all HIPAA requirements. Assist co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions.
Communicates to supervisors any barriers to completing assignments or daily work with delegates in an efficient and effective manner. Demonstrates reliability and good attendance and punctuality standards.
Perform other duties as assigned.
Associate's Degree or Bachelor's Degree in RN in Nursing or other health related field.
Master's Degree in Nursing or other health related field.
With Associate's or Bachelor's Degree: 5 years experience in a clinical setting and in a managed care plan performing UM oversight, including auditing.
Good working knowledge of licensure and regulatory requirements, and accreditation standards; Managed Health Care experience.
Knowledge of issues pertaining to Medi-Cal, Medicare, and other HMO & IPA contracts & payers.
Ability to manage and organize large volumes of data; Knowledge of regulatory and accreditation entities and their requirements.
Excellent verbal and written communication skills; excellent interpersonal skills.
Proficient in MS Office applications.
Ability to work independently.
Ability to solve complex problems/issues and identify creative solutions.
Current and unrestricted CA RN License
Certified Professional Utilization Review (CPUR)
Certificate in Case Management (CCM)
Certified Professional in Healthcare Quality (CPHQ)