Healthcare Svcs Review Nurse
About The Position
Coordinate and perform quality monitoring of services that provide care to the indigent citizens of the County enrolled in the Hillsborough County Health Care Plan (HCHCP). Assist contracted providers (physicians, hospitals, ancillary providers/facilities) with quality assurance aspects of their care to enrolled clients. Maintain uniform protocols followed by all contracted providers to ensure appropriate care to clients. Represents the County as its clinical liaison for the Drug Review Committee and the BOCC established Medical Subcommittee to advise on clinical and utilization issues. Serves as a resource for the HCHCP. Conducts special projects relating to the HCHCP. Manages communications and cooperation amongst the four networks and the care they provide to our clients.
Requirements
- Possession of a valid State of Florida Registered Nurse license
- Five years of general medical or surgical nursing experience to include two years performing Quality Assurance, Utilization Review or Case Management duties
- Possession of a valid Florida Driver’s License
- Knowledge of nursing theory and practices.
- Knowledge of general medical and surgical nursing techniques and procedures.
- Knowledge of Quality Assurance policies and procedures.
- Knowledge of the National Committee on Quality Assurance (NCQA) standards.
- Knowledge of Utilization Review and Case Management policies and procedures.
- Knowledge of Disability Determination criteria.
- Ability to collect, organize and evaluate data and to develop logical conclusions.
- Ability to follow oral and written instruction and ability to use a computer and related software.
- Ability to prioritize work and work effectively with others.
- Ability to communicate effectively both orally and in writing.
Nice To Haves
- Knowledge of Federal, State and community resources within Hillsborough County is preferred.
- Bilingual in English and Spanish
- At least three years experience working with Excel and Word.
- Experience working for a payor/insurance provider is desired.
Responsibilities
- Monitor procedural compliance of network providers.
- Pursue quality of care inquiries.
- Review medical records to determine accepted standards of care have been rendered and appropriately performed.
- Plan agenda and prepare materials for HCAB Medical Subcommittee and Drug Review Committee meetings and promote attendance.
- Attend Committee meetings and provide input and direction as applicable.
- Function as a quality assurance liaison between the networks, providers and hospitals on client issues.
- Participate and assist with the performance improvement programs of networks, providers and hospitals.
- Provide patient outcome feedback as requested.
- Identify training issues, prepares reports and related documentation.
- Execute special projects involving the care of HCHCP clients.
- Perform other special assignments, research and prepare reports, develop and implement programs.
- Performs other related duties as required.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
