RN Quality, Safety, Peer Review Oversight Specialist IV, Health Plan

Job Summary:

In addition to the responsibilities listed above, this position is also responsible for supporting senior staff in providing oversight of systems designed to monitor and ensure the quality care and services are provided at a comparable level to all members and patients across the continuum of care; serving as a point of escalation for routine issues in quality improvement systems; ensuring that the organization meets the standards established by regulatory agencies and accreditation organizations and meets public expectations independently; ensuring the integrity of systems related to the selection, credentialing and competence of physicians and other health care practitioners; utilizing systems for granting or terminating clinical privileges, professional staff or medical staff or clinical staff membership, proctoring and continuing education independently; participating in the review and approval of medical staff or provider staff Bylaws, Rules and Regulations and amendments; and providing oversight for systems of all contracted entities including but not limited to the Permanente Medical Groups.

Essential Responsibilities:

+ Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.

+ Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.

+ Serves as the subject matter expert for clinical quality improvement processes and regulations within assigned departments by: maintaining awareness of current internal policies and external regulations; participating on committees, projects to propose a course of action on the enforcement, development of policies or procedures of regulations and auditing processes; maintaining collaborative, results oriented partnerships with practitioners and/or staff across clinical and administrative roles to ensure compliance with regulations and improve patient safety, reporting accuracy, and health outcomes and provides insight to the regulation climate; delivering educational programs to raise awareness for regulation requirement, internal concerns, and system/database usage; and anticipating issues, weighing practical considerations in addressing issues, and seeking input from engagement manager/sponsor to resolve.

+ Facilitates quality of care complaints and the review process by: participating in grievance meetings, cases, reviews, referrals, or other mechanisms as needed and making recommendations based on available evidence and assessing if the quality of care complaint can be substantiated; providing and reviewing all documentation, records, chart reviews, staffing reviews, and the information requested; proactively coordinating with the appropriate individuals/teams to ensure the quality of care concern is referred to the right team and monitoring the process flow of investigations and claims as requested; and monitoring cases, quality care incidents, and near misses according to established protocols on an ongoing basis.

+ Delivers infection prevention and control programs to improve employee and patient safety by: conducting epidemiological research as a part of prevention and surveillance, outbreak management as requested; and adhering to outbreak protocols and leading all outbreak containment efforts within the area of focus.

+ Facilitates clinical quality improvement oversight risk management efforts by: assisting with the development of corrective action plan for areas of improvement identified through utilization review, clinical records audit, claim denials, patient satisfaction surveys, and auditing surveys; conducting root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches in order to identify areas of improvement; assisting with escalating high-risk issues and trends to appropriate entity for resolutions; and utilizing health outcome analysis to continuously monitor oversight effectiveness.

+ Delivers patient safety and satisfaction programs and initiatives by: identifying and resolving safety hazards, accidents, incidents, threats, and significant events promptly and following up accordingly; and delivering patient care and satisfaction programs which aim to improve patient flow, clinical support, patient services, and seamless transition of care.

+ Develops new clinical quality improvement programs by: consulting with practicians, teams, and departments to develop guidelines, metrics, and operational definitions of quality improvement through qualitative and quantitative program evaluation, analyzing program performance, and peer/department review groups; leveraging a variety of health concepts, regulatory requirements, and change management principles to develop programs which optimize clinical quality, safety, or health outcomes; and integrating continuous learning orientation into programs to assist with oversight, development, and improvement initiatives.

+ Enters and reports data from systems, procedures, and forms to improve data management programs and utilizes data from internal and external sources to monitor and evaluate quality improvement initiatives by: conducting descriptive and inferential statistical analysis for complex quality improvement evaluations; analyzing data from databases, vital statistics, hospital patient discharge data, claims, and other relevant health sources; and preparing and presenting reports (e.g., infection control research, utilization reviews, population health needs analysis, patient satisfaction) into specified formats within assigned area.

+ Conducts regulatory audits and surveys by: coordinating with departments and external representatives for onsite visits and evaluations; delivering requested routine and ad hoc audit documentation, information, reports, and tools throughout the auditing process; and coordinating with practitioners and employees within designated departments to ensure the completion of required auditing surveys.

+ Coordinates within assigned areas to evaluate the cost effectiveness, practicality, appropriateness, and equal application of care to diverse patients by: preparing forms, materials, and documentation for case reviews; supporting the development of the standard operating procedures for treatment for specific medical codes to ensure equal and timely access to care; evaluating current patient treatment plans to ensure patient needs are met in a timely manner and escalates issues to senior leaders; facilitating discussions between practitioners, staff, and patients to identify population health needs, such as community health concerns, access to transportation, knowledge of rights, reducing no shows, and others, and providing recommendations to senior leaders; and evaluating previous patient cases to identify areas of improvement for length of stay, type of treatment, time of treatment, and barriers to treatment (e.g., language barriers and mobility accessibility) as requested.

Minimum Qualifications:

+ Minimum one (1) year of experience in a leadership role with or without direct reports.

+ Minimum two (2) years of experience with databases and spreadsheets.

+ Minimum two (2) years of experience delivering training programs.

+ Minimum two (2) years of experience in clinical setting, health care administration, or a directly related field.

+ Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum three (3) years of health care experience or a directly related field OR Minimum six (6) years of experience in health care or a directly related field.

Additional Requirements:

+ Knowledge, Skills, and Abilities (KSAs): Compliance Management; Health Care Data Analytics; Learning Measurement; Managing Diverse Relationships; Delegation; Project Management; Health Care Quality Standards; Quality Improvement; Quality Assurance and Effectiveness; Evidence-Based Medicine Principles

COMPANY: KAISER

TITLE: RN Quality, Safety, Peer Review Oversight Specialist IV, Health Plan / Hospital

LOCATION: Oakland, California

REQNUMBER: 1313624

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.