Quality Assurance Nurse and Compliance Specialist
2 weeks ago
Positions available for a Quality Assurance Nurse and a Compliance Specialist.
QUALITY ASSURANCE NURSE
OBJECTIVE:
The Quality Assurance Nurse plays a crucial role in collaboration with the Medical Director, the VP of Clinical Policy, and the Quality Management Committee to develop, implement, and enhance the Quality Management Program. This position also involves overseeing Health Plan Audits and managing responses to Appeals and Grievances.
KEY RESPONSIBILITIES:
- Facilitates and participates in Quality Management Committee meetings, preparing agendas and documenting minutes to ensure effective processes.
- Assists in the creation and upkeep of the Quality Management Plan, annual work plan, and quarterly reports in partnership with the Quality Management Committee.
- Collaborates with the VP of Clinical Policy and Client Health Services Department to establish quality standards and clinical benchmarks.
- As part of quarterly reporting, develops Quality Management processes by tracking and analyzing data to identify patterns of under and over-utilization.
- Coordinates Quality Management functions across the Medical Management Department, Physician Group, Health Plan, and outpatient care settings to ensure improvements in both clinical care and service delivery.
- Oversees and manages Health Plan audits, including the preparation of all necessary documentation.
- Reviews and processes appeals and grievances from the Utilization Management department in accordance with established policies and procedures.
- Develops and monitors compliance with corrective action plans (CAP) following health plan audits and regulatory assessments.
- Acts as a liaison for all affiliated health plans.
COMPLIANCE SPECIALIST
The Compliance Specialist supports the Quality Assurance Nurses in preparing for audits. This role includes reviewing audit tools, requesting authorization universes, and preparing files for audit submission.
Company OverviewThrifty Management Services serves as the dedicated Management Services Organization (MSO) for Preferred IPA of California, delivering exceptional care management, coordination, and claims processing services to Preferred IPA and its members. We collaborate with the network's participating physicians to facilitate patient care when referrals are made to specialists or hospitals for diagnosis and treatment. Our commitment is to ensure seamless patient care across all facets of the provider network, providing high-quality services to participating physicians and superior healthcare to our members.
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