Quality Review Nurse, RN

3 weeks ago

Rancho Cucamonga, United States Alura Workforce Solutions Full time
Position

Quality Review Nurse, RN

Description

MUST live in California and be able to wrok a hybrid position.

Reporting to the Manager of Provider Quality Oversight, the Provider Quality Review Nurse, RN is responsible for:
- Receive and research all PQI and QR cases as assigned, provide a summary and recommendations to the Medical Director of case assignments.
- Effectuate all action items as determined by the Medical Director to resolution of case assignments.
- Reviewing escalated issues
- Discussing, and reviewing cases with Medical Directors referred to the Quality Management (QM) department.
- Investigation of cases includes, but not limited to, the documentation of case summaries, follow up actions, outreach efforts, and communications in the QM database.
  1. Investigate and complete case summaries and make recommendations for any Potential Quality of Care Incidents (PQI) referred to the QM department.
  2. Maintain direct communication with departments, external facilities including hospitals, Skilled Nursing Facilities, and/or Providers to ensure all PQI issues are thoroughly investigated, and care is coordinated in a timely manner, as needed.
  3. Review requested medical records to ensure complete case documentation is received from all practitioners, providers, and entities/agencies to ensure thorough investigation of the issue.
  4. Review case findings and recommendations with Medical Director. Issue Corrective Action Plans (CAP), review CAP responses, draft Opportunity for Improvement letters, and coordinate other interventions as needed to ensure all issues were addressed and future occurrences of the same issue are mitigated.
  5. Complete data entry into database systems, maintain updated documentation and other tracking mechanisms for all cases.
  6. Review and execute ad hoc requests, quality reviews, and/or focused audits, as needed.
  7. Escalate issues of non-compliance to the Quality Systems Management team.
  8. Maintain working knowledge of regulatory requirements as they relate to QM operations and protocols.
  9. Complete other tasks and assignments based on department and business needs.
  10. Demonstrate a commitment to incorporate LEAN principles into daily work.
Requirements
  • Three (3) or more years of any individual or combined healthcare experience in quality assurance, quality management, quality improvement, utilization management, discharge planning, and/or case management. Three (3) or more years of work experience in a managed care, hospital, provider practice, or other comparable healthcare experience
  • Experience preferably in a quality/performance improvement setting.
  • Bachelor's degree in Nursing from an accredited institution required.
  • In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above.
  • Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Clinical certification in area specialty) preferred.
  • Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.
  • Yes, must have a valid California Driver's License.
  • Excellent understanding of performance improvement, quality assurance, and utilization management. Knowledgeable in clinical analysis of health records, assessing or evaluating quality, and identifying problems or issues with care delivery.
  • Microcomputer applications: spreadsheet, database, and word processing. Excellent written and verbal communication skills. Excellent coordination skills. Ability to communicate findings and form recommendations based on clinical case reviews.
Additional information
  • Remote- MUST live n California

INDH

  • Special Investigations Unit Medical Reviewer

    3 weeks ago

    Rancho Cucamonga, United States IEHP Full time

    What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to...

  • Senior Special Investigations Unit Medical Reviewer

    3 weeks ago

    Rancho Cucamonga, United States IEHP Full time

    What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Under minimal supervision, the Senior Special Investigations Unit Medical Reviewer (Senior SIU Medical Reviewer) performs clinical and complex reviews of medical...

  • Special Investigations Unit Medical Reviewer

    3 weeks ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    What you can expect!  Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare...

  • Senior Special Investigations Unit Medical Reviewer

    3 weeks ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    What you can expect!  Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under minimal supervision, the Senior Special Investigations Unit Medical Reviewer (Senior SIU Medical Reviewer) performs clinical and complex reviews...

  • Utilization Review Case Manager

    6 days ago

    Rancho Cucamonga, United States CorVel Full time

    The Utilization Review Case Manager is responsible for reviewing inpatient and outpatient medical treatment to ensure its medical necessity and assigning appropriate length of stay. This is a remote position for candidates living in Pacific Time Zone. Essential Functions & Responsibilities: Communicate specific issues of concern with the appropriate claims...

  • Quality Improvement Program Manager, RN

    1 week ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of department leadership, the Quality Improvement Program Manager will drive quality improvement initiatives across the continuum of care...

  • Nursing Supervisor RN/Registered Nurse

    4 days ago

    Rancho Cucamonga, California, United States Kindred Healthcare Full time

    ScionHealth is committed to a culture of service excellence as demonstrated by our employees' adherence to the service excellence principles of Pride, Teamwork, Compassion, Integrity, Respect, Fun, Professionalism, and Responsibility.As our most acute level of care, our specialty hospitals offer the same critical care patients receive in a traditional...

  • Quality Improvement Nurse, RN

    4 weeks ago

    Rancho Cucamonga, United States IEHP Full time

    Start your journey towards a thriving future with IEHP and apply TODAY!Pay RangeUSD $43.87 - USD $58.13 /Hr.What you can expect! Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and IEHP departments on HEDIS improvement related issues, serving as...

  • Quality Improvement Nurse, RN

    4 weeks ago

    Rancho Cucamonga, United States IEHP Full time

    Start your journey towards a thriving future with IEHP and apply TODAY!Pay RangeUSD $43.87 - USD $58.13 /Hr.What you can expect! Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and IEHP departments on HEDIS improvement related issues, serving as...

  • Quality Improvement Nurse, RN

    4 weeks ago

    Rancho Cucamonga, United States IEHP Full time

    Start your journey towards a thriving future with IEHP and apply TODAY!Pay RangeUSD $43.87 - USD $58.13 /Hr.What you can expect! Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and IEHP departments on HEDIS improvement related issues, serving as...

  • Quality Improvement Nurse, RN

    11 hours ago

    Rancho Cucamonga, United States IEHP Full time

    Start your journey towards a thriving future with IEHP and apply TODAY!Pay RangeUSD $43.87 - USD $58.13 /Hr.What you can expect! Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and IEHP departments on HEDIS improvement related issues, serving as...

  • Quality Improvement Program Manager

    7 days ago

    Rancho Cucamonga, United States Inland Empire Health Plans Full time

    What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of department leadership, the Quality Improvement Program Manager will drive quality improvement initiatives across the continuum of care...

  • Special Investigations Unit Medical Reviewer

    4 weeks ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    **What you can expect!** Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an **authentic experience!** Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and...

  • Quality Improvement Program Manager

    3 weeks ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    What you can expect!Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!Under the direction of department leadership, the Quality Improvement Program Manager will drive quality improvement initiatives across the continuum of care...

  • Quality Engineer

    3 weeks ago

    Rancho Cucamonga, United States Amtec, LLC Full time

    The Quality Engineer is responsible for ensuring product quality through all levels of the supply chain of a vertically integrated manufacturer. The Quality Engineer plans and conducts activities with both internal and external stakeholders to control production processes through implementation of inspection plans, failure analysis investigations, and...

  • Quality Improvement Program Manager

    2 weeks ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    Overview: What you can expect! Find joy in serving others with IEHP! We welcome you to join us in healing and inspiring the human spirit and to pivot from a job opportunity to an authentic experience! Under the direction of department leadership, the Quality Improvement Program Manager will drive quality improvement initiatives across the continuum of care...

  • Integrated Transitional Care Nurse, Lvn

    1 week ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    Overview: **What you can expect!** Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an **authentic experience!** Join the dynamic Integrated transitional Care team, directed by our visionary leaders! As an integrated Transitional care Nurse LVN,...

  • Integrated Transitional Care Nurse, Lvn

    1 week ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    **What you can expect!** Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an **authentic experience!** Join the dynamic Integrated transitional Care team, directed by our visionary leaders! As an integrated Transitional care Nurse LVN, you’ll...

  • Clinical Practice Coach

    3 weeks ago

    Rancho Cucamonga, United States Inland Empire Health Plan Full time

    What you can expect!Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!The Clinical Practice Coach & Oversight, Enhance Care Management (ECM), RN will be under the work direction of the Practice Coach Manager for ECM. ECM is a...

  • Registered Nurse | ECM

    2 weeks ago

    Rancho Cucamonga, United States Chaparral Medical Group Full time

    Job DescriptionJob DescriptionJob DescriptionThe Enhanced Care Management (ECM) RN will be responsible for coordinating the care of patients enrolled in Chaparral's ECM program. The ECM RN is also responsible for Clinical Oversight of ECM Lead Care Managers to address the patient's medical and behavioral health needs. They will be active members of...