QI Nurse Specialist
2 weeks ago
The Quality Improvement Nurse reports to the VP and Director of QI and carries out the day-to-day activities related to ensuring compliance to QI Standards and State and Federal Regulations by auditing staff work case files using standardized tools implemented by the QI Department Director. The role of the QI Team Nurse is to promote and support the quality and cost effectiveness of medical care through the monitoring and distribution of production and daily auditing for quality. The QI Nurse will also serve as an intra-team contact for staff for questions on appeals and grievances and offers assistance as may be needed. The QI Nurse is a key member of the QI Department Team and works closely with the Medical Director, Director of QI, various Executive-level department heads and contacts, and Health Plan Representatives. The QI Nurse adheres to NCQA, State and Federal and other Regulatory agency standards and turn-around times while carrying out the QI duties and responsibilities.
Essential Duties and Responsibilities include the following:
- Performs staff case file audits using standardized tools and gives suggestions for improvement on processes as may be necessary.
- Understand, promote and audit the principles of QI to facilitate the accurate and timely Grievances & Appeals.
- Acts as the key contact to the QI VP and Director.
- Carries out the direction or instructions for QI activities as given by the Medical Director or QI Director.
- Acts as a key contact to network physician and their staff and its associated IPAs.
- Is responsible for a case load.
- Responsible for setting personal goals and timetables and coordinates activities to ensure smooth workflow and time management.
- Identifies and analyzes problems and takes steps to provide suggestions for solutions as appropriate.
- Acts in concert with other staff to problem-solve member issues and give feedback on Appeals and Grievance activities.
- Ability to make sound decisions and present and implement company policies, procedures and goals and ensure that the QI P & P are followed.
- QI Team Nurse Specialist is a key member of the QI Department and Assists QI staff as needed in order to complete work.
- Assists in the coordination of activities related to QI clinical studies, such as but not limited to, over/under utilization in order to promote good patient health outcomes.
- QI Team Nurse Specialist may produces charts, graphs, reports to demonstrate results and outcomes.
- Participates in health plan audits and assists with any corrective actions, as necessary for process improvement.
- Travels to physician offices or meetings, as may be necessary, to perform QI Department activities.
- Prepares and maintains records and files which are neat, organized, thorough and readily accessed.
- Completes assignments within specified timelines.
- Communicates with internal and external customers in a professional manner and follows through on commitments.
- All written and verbal communication and transmission of information is professional, clear, concise and in proper business and grammatical format.
- Adheres to Confidentiality and HIPAA regulations.
- Filing, faxing, copying, purging of files.
- Performs all other duties as assigned by management.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.
Education and/or Experience:
- Bachelors degree.
- Minimum on (3-5) years of Quality Management experience.
- Three to five (3-5) years of managed healthcare experience preferred.
- Computer proficiency in use of Word, PowerPoint, Excel and Internet.
- Must have California driver's license, use own vehicle for business related travel and be responsible for all liability on vehicle.
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