Quality of Care Investigative Nurse

Hybrid.
Remote Work:The first day would need to be in person to obtain equipment and complete necessary security training to be able to access systems.
Quality of care Investigative Nurse This position reports to the Client
- Quality Management Unit and conducts quality-of-care investigations pursuant to the contract between the client and the Health Care Cost Containment System (HCCCS).
This position participates in investigations of member-centric and systemic quality-of-care concerns to ensure member health and well-being.
Conducts timely, thorough, member centric, and systemic investigations of all division member quality-of-care issues and implements vendor-specific corrective action plans, utilizing a standardized process.
Makes appropriate referrals to oversight and regulatory agencies.
Participates in Care Concerns, Care Needed today, and member issues as assigned.
Maintains all necessary documentation to support case work.
Request appropriate documentation for quality-of-care investigations and ensure the maintenance of comprehensive case records to support allegation review and substantiation levels.
As a result of the QOC Investigation, issue remediation or a Corrective Action Plan to the vendor, and ensure all applicable investigative information and documents are uploaded within the client QMS Portal.
Appropriately elevates cases and/or trend concerns to the QOC supervisor.
Overview:We need nurses who can investigate complex cases, analyze information from multiple sources, identify inconsistencies or patters, and write detailed, defensible reports.

Skills:
Critical Thinking Clinical Judgment Professional Report writing Technological skills, including the use of databases, Microsoft Office products, email, and electronic referral and verification sources.
Producing professional technical reports and letters.
Research and analysis.
Oral and written communication skills.
Personal planning, organization, and time management.
Medical chart review.
Nursing Process, including assessment, monitoring, and evaluation.
Decision-making skills.
Critically analyze problems and develop effective plans for corrective action.
Required

Education:
Active license to practice as a LPN or RN in AZ.
Preferred

Qualifications:
For the extensive experience we are seeking the nurses will typically have a Bachelors Degree (BSN), Masters degree or doctoral -level.
Experience preparing formal investigative reports, conducting clinical research, performing quality of -care reviews or evaluating compliance with clinical standards.
Background in healthcare quality assurance risk management utilization review, clinical auditing, regulatory compliance or patient safety.
Experience analyzing complex cases that require synthesis of extensive records and evidence-based conclusions.
Required Skills 6 months to a year of risk management, quality assurance nurse or auditing experience Active license as a Registered Nurse (RN) in AZ Notes:Hybrid Schedule:Remote Work:The first day would need to be in person to obtain equipment and complete necessary security training to be able to access systems.8am -5pm no weekends 40 hours per week.
VIVA is an equal opportunity employer.
All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job.
This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.