Supervisor, Utilization Management Clinical Quality Nurse Reviewer RN

Salary Range:  $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.)

 

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.
 

Job Summary

The Supervisor Utilization Management (UM) Clinical Quality Nurse RN, is responsible for executing the day-to-day operations as it relates to the monitoring the Clinical Quality Review nursing staff’s responsibilities and activities. This includes, but not limited to, ensuring proper assignment and coverage of clinical auditing tasks, potential quality issue reviews; monitoring and evaluating functional team operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, functional team and departmental expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems as they related to Clinical Audits and forming resolution within the scope of work/licensure. The Supervisor supports regulations, policies, protocols, and procedures of the department.

The Supervisor, UM Clinical Quality RN is responsible in understanding the operational procedures across multiple different teams within the department to ensure that our practices and supporting documentation are compliant with all regulatory requirements. The incumbent ensures all functions of the UM QA Clinical Quality team are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of LA Care's culturally diverse membership.

The Supervisor is responsible for the external audits and leads pre-audit preparation as well as post-audit follow-up.  This position actively participates in the operationalization of internal L.A. Care policies and procedures to ensure compliance with regulatory guidelines and mandates. The position supervises all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Ensures adequate/appropriate distributions of workforce, assignments and time off requests.  Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Responsible for the daily workflow and leading the work of assigned staff.  This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff.

Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs.  Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines

Serves as the primary resource for all clinical audit-related questions/issues raised by staff; escalates to appropriate leader/team when necessary.

Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals.   Focus on UM cases for all lines of business in order to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. 

Facilitate training in conjunction with the Educator, RN to supports migration/launch of new system(s) or workflows, and develops auditing tools to match. Including but not limited to assisting with creating and updating desktop procedure training documentation, or job aids.

Responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation and works along side other Subject Matter Experts (SMEs) and Leadership to facilitate change management and implementation of new or updated workflows as needed.

Duties Continued

Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions.

Performs data mining and analysis and create reports on audit findings, as well as make recommendations, to submit to the department's Quality Assurance Team and UM Management. Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of