The Utilization Management Policy Initiatives Nurse RN II, under the purview 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. This position will be responsible for curating our clinical decision making resources, using data on clinical polices and authorizations to update our prior authorizati...