QI Nurse

What You Will Be Doing:

Under general supervision, performs quality improvement activities related to HEDIS, facility site review, and complaint/grievance resolution. In addition, this position is responsible for planning, implementing and monitoring quality improvement activities to ensure members receive quality care in compliance with HPSJ, regulatory and contractual requirements. Work is semi-routine and occasionally varied and moderately complex, and requires a limited to moderate degree of discretion and independent judgment.

Remote, must reside in California

Facility Site Reviews

• Schedules and conducts facility site reviews as required.
• Develops corrective action plans based on findings; submits for approval.
• Implements approved corrective action plans; collaborates with provider to resolve.
• Monitors, analyzes and reports on progress; escalates as required.

HEDIS

• Assists with development of, and implements external and internal quality improvement plans, based on HEDIS results.
• Conducts HEDIS chart audits.
• Monitors, analyzes and reports on progress of corrective action plans; escalates as required.

Internal QI

• May plan internal quality improvement activities for identified problems using PDCA:
• Leads the CQI team in the identification and analysis of process barriers.
• Makes recommendations to resolve and implements approved recommendations.
• Monitors, analyzes and reports on progress; escalates as necessary.
• Conducts internal quality audits as directed; reports on findings.

Complaints and Grievances

• May research and analyze identified clinically related external complaints and grievances.
• Identifies and recommends solutions; submits as required.
• Implements approved corrective action plans; monitors and reports on results.
• Participates on high level committees; prepares reports; compiles and analyzes data; makes recommendations based on findings.
• Implements quality initiatives identified by statewide collaborates; compiles and analyzes data; prepares and submits reports as required.
• Assists with DHS audits; develops QI processes based on findings.

What You Bring:

Required

• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Strong clinical skills.
• In-depth knowledge of Title 22 regulations and NCQA standards.
• In-depth knowledge of the principles and practices of quality improvement, including HEDIS.
• Basic knowledge of Medi-Cal and/or Medicare programs and regulations as they related to quality improvement.
• Basic knowledge of quality metrics.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Ability to read, interpret and apply complex written regulations, guidelines, clinical information and other materials.
• Strong analytical, assessment and problem solving skills.
• Basic negotiation skills.
• Strong research and analysis skills.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong oral and written communication skills with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information and document according to standards.
• Ability to work independently and as part of a team.
• Ability to use tact and diplomacy to diffuse emotional situations.
• Intermediate skills in Word and Excel, including the ability to create charts and graphs.
• Basic PowerPoint skills.
• Strong mathematics skills.
• Strong customer service skills.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

What you Have:

Education and Experience:

Required

• Graduation from an accredited nursing school.
• Five or more years clinical nursing experience.

Preferred

• Three or more years’ experience performing quality activities in a healthcare setting.
• Experience in managed care.
• Experience working with Medi-Cal and/or Medicare populations.

Licenses, Certifications

• Unrestricted Registered Nurse license.
• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.