Clinical Policy Nurse RN II

Job Summary

The Clinical Policy Nurse RN II is responsible for analyzing clinical financial data to assess the effectiveness of existing and proposed policies. This role involves reviewing and interpreting clinical, utilization, and financial data to identify trends, opportunities for policy improvement, and cost savings. Additionally, this position plays a key role in translating regulatory impacts into operational strategies and collaborating with internal and external stakeholders to ensure clinical policies support safe, effective, and compliant care delivery.

Duties

• Audit federal, state, and local legislation, regulatory guidance, and health care policies to identify potential impacts on clinical practice, reimbursement, and organizational operations.
• Review and interpret clinical, utilization, and financial data to identify trends, opportunities for policy improvement, and cost savings.
• Research, develop, and evaluate clinical and health policy designed to improve patient outcomes, detect and mitigate Fraud, Waste, and Abuse (FWA), and streamline organizational processes.
• Monitor the implementation of health programs, clinical initiatives, and community action plans to assess effectiveness, compliance, and impact on patient outcomes.
• Collaborate with internal stakeholders to evaluate utilization trends and anomalies and contribute to policy development aimed at improving efficiency and compliance identified during risk assessments.
• Prepare analytical reports, summaries, and analyses assessing policy performance, regulatory impact, and communicate insights and recommendations to stakeholders to drive evidence-based policy and impacted outcomes.
• Present findings, recommendations, and action plans to key stakeholders.
• Participate in work groups related to healthcare services clinical policies and procedures including efforts to improve department processes, as needed.

Education & Experience

• Education: Bachelor’s degree in Nursing preferred.
• Experience:
  • At least 5 years of experience in Clinical Nursing.
  • At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.

Skills

• Strong analytical and critical thinking skills with the ability to interpret regulatory requirements and legislation.
• Ability to translate regulatory requirements into auditable tools.
• Ability to perform independent research on complex medical topics.
• Excellent verbal and written communication skills.
• Strong problem-solving and team-building skills.
• Ability to work independently with strong self-direction.
• Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools.
• Ability to work effectively with diverse teams in cross-functional work groups.
• Strong organizational and time-management skills.

Additional Information

• Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.).
• Benefits: Paid Time Off (PTO), Tuition Reimbursement, Retirement Plans, Medical, Dental and Vision, Wellness Program, Volunteer Time Off (VTO).
• Location: Los Angeles, CA, US, 90017.