Clinical Advisor

Overview

Under guidance from the CC Manager of Regulatory Performance, the Clinical Advisor isresponsible for drafting, editing, reviewing, auditing, tracking, monitoring and maintainingpolicies and procedures for Partnership HealthPlan of California. Alongside designatedorganizational leadership ensures compliance with governing rules, regulations, and/oraccreditation standards. Reviews both draft and final All Plan Letters (APLs) and/or regulatorychanges and supports leaders with the research, planning, implementation and/or operationalreadiness submissions across the organization.The Clinical Advisor may support new and ongoing training and staff support needs within theCare Coordination department through the translation of regulatory requirements to operationaltraining, and assist the Care Coordination leadership team on necessary audits and projects.

Responsibilities

▪ Performs policy research to analyze current and/or new regulations by applicablePartnership regulators and/or accrediting agencies (ex: DHCS, DMHC, CMS, NCQA,etc.).▪ Reviews timely draft and/or final All Plan Letters (APL), Policy Guides and/or otherDHCS guidance for policy impact.▪ Proactively identifies policies impacted by regulatory changes.▪ In collaboration with stakeholders throughout the organization, drafts and prepares newpolicies.▪ In collaboration with the CC Regulatory Performance Manager and Quality & TrainingSupervisor develops training program courses and materials in accordance with Partnershippolicies & procedures.▪ Provides mentorship, direction, resources, training and/or orientation to clinical CareCoordination staff; maintaining and active working knowledge of all departmentalpolicies/procedures.▪ Creates effective training materials including but not limited to desktops, flyers, FAQs,informational emails, newsletters, etc.▪ Assess existing training materials and other offerings and recommends changes to meetdepartmental objectives and Partnership policies & procedures.▪ Assist in reviewing and maintaining up-to-date knowledge NCQA regulations concerningcare coordination activities and programs.▪ Supports clinical file review for internal and external NCQA to ensure program goals,quality standards and department metrics are met.▪ Supports departmental NCQA auditing and tracking activities.

▪ Assist in maintaining departmental library of required NCQA documents and reports forauditing purposes.▪ Prepares all policies and/or related materials for appropriate committees’ review and/orsubmission to associated regulatory or accrediting agencies.▪ Supports Partnership audit and compliance readiness by submitting all materials timely.▪ Serves as PowerDMS ‘Super User’ in the organization to effectively route policies withmulti-departmental impacts to appropriate reviewers.▪ Participates in audits with Partnership’s regulatory and/or accreditation bodies bypreparing policies, documents and/or reports as needed.▪ Communicates and coordinates across the organization to ensure that all active and currentPartnership policies are available and reflected on Partnership websites.▪ Conducts analysis, collect information, and evaluates the impact of regulatory andcompliance issues to inform auditing and monitoring activities.▪ Analyzes the impact of new programs/benefits and efficacy of existing processes, policies,procedures and trainings.▪ Consults with department leadership on a wide variety of compliance related subject matterareas as it relates to policies and procedures.▪ Attends all major committee meetings as policy and procedure advisor and key consultanton policy and procedure matters.▪ Works collaboratively with care coordination leadership to identify and implementstrategies to improve quality and compliance.▪ Other duties as assigned.

Qualifications

 

Education and Experience

Associate’s degree in Nursing required; Bachelor’s degree in Nursing(or higher) preferred. Three (3) years of cumulative case managementexperience required, or equivalent combination of education andexperience. General knowledge of managed care and/or experiencewith Medicaid population preferred

 

 

Special Skills, Licenses and Certifications

Current unrestricted California Registered Nurse License. Thoroughknowledge of utilization and case management programs, criteria, andprotocols. Certification in case management (Commission for CaseManagement (CCM), Board Certification in Case Management(RNBC), Public Health Nurse Licensure, or advanced nursing licensure,or other certification demonstrating appropriate essential skills ispreferred. Strong program evaluation, auditing and management skills.Strong organizational skills required. Computer literacy and proficiency.Valid California driver’s license and proof of current automobileinsurance compliant with Partners