Nurse Evaluator II

About the role

To assure the proper and efficient operation of the Medi-Cal Program, the Nurse Evaluator II within the Data Analytics & Case Development Branch, uses professional nursing knowledge, expertise and judgment to perform program integrity functions which include onsite reviews of Medi-Cal providers, evaluation of medical documentation of services and drugs, and provision of expert medical testimony at administrative appeal and criminal hearings in collaboration with management and legal counsel.

The incumbent must have the ability to act independently, be flexible, open-minded, and tactful in dealing with team members, audit leads, managers, and executive management. The incumbent must be able to accurately convey medical program integrity findings effectively, both orally and in written form.

Travel of up to 10% is required, including statewide overnight travel may be necessary to complete audits, attend training, meetings and other activities as directed by management. Incumbent must be able to travel to provider sites and be flexible to travel on short notice.

Responsibilities

• Perform onsite reviews of Medi-Cal providers
• Evaluate medical documentation of services and drugs
• Provide expert medical testimony at administrative appeal and criminal hearings
• Collaborate with management and legal counsel
• Act independently and be flexible, open-minded, and tactful in dealing with team members, audit leads, managers, and executive management
• Accurately convey medical program integrity findings effectively, both orally and in written form
• Travel up to 10% of the time, including statewide overnight travel

Requirements

• Maintain a valid and active registered nursing license with the California Board of Registered Nursing
• Education: If you are meeting minimum qualifications with education, you must include a copy of your diploma/degree and/or unofficial/informal transcripts for verification. Official transcripts may be required upon appointment.

Qualifications

• Minimum requirements as outlined in the Class Specification

Skills

• Strong clinical expertise
• Experience in identifying fraud, waste or abuse
• Regulatory and policy knowledge
• Good communication skills (both written and verbal)
• Strong ability to analyze complex clinical and billing information
• Technical and data competency
• Strong adaptability and organizational skills

Benefits

• Medical, including health, dental, and vision insurance
• Paid holidays and vacation/leave
• Defined retirement program
• Savings Plus Program (401(k), 457)
• Medical/Dependent Care Reimbursement Accounts