Provider Quality Review Nurse, RN

Inland Empire Health Plan•Rancho Cucamonga, CA

1d•Remote

About The Position

This is a short-term assignment where you can 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! At Inland Empire Health Plan (IEHP), we believe the highest quality of care should be delivered to all in the Inland Empire. We are thinking beyond the way Quality is viewed today – we believe it should be holistic and transformative. IEHP’s provider incentive programs serve an important role in achieving IEHP’s quality goals. Reporting to the Manager of Provider Quality Oversight, the Provider Quality Review Nurse, RN is responsible for receiving and researching all PQI and QR cases as assigned, providing a summary and recommendations to the Medical Director of case assignments, and effectuating all action items as determined by the Medical Director to resolution of case assignments. This role involves reviewing escalated issues, discussing and reviewing cases with Medical Directors referred to the Quality Management (QM) department, and investigation of cases which includes, but is not limited to, the documentation of case summaries, follow up actions, outreach efforts, and communications in the QM database. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

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.
Possession of an active, unrestricted, and unencipbered Registered Nurse (RN) license issued by the California BRN required
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
Ability to demonstrate critical thinking, strong problem-solving capability.
Strong attention to detail
Ability to prioritize work to ensure adherence to project deadlines.
Ability to effectively escalate issues as identified, following established protocols
Positive attitude and ability to work in a team setting
Self-direction and ability to work with minimal supervision
Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire

Nice To Haves

Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Clinical certification in area specialty) preferred

Responsibilities

Investigate and complete case summaries and make recommendations for any Potential Quality of Care Incidents (PQI) referred to the QM department.
Maintain direct communication with IEHP 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.
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.
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.
Complete data entry into database systems, maintain updated documentation and other tracking mechanisms for all cases.
Review and execute ad hoc requests, quality reviews, and/or focused audits, as needed.
Escalate issues of non-compliance to the Quality Systems Management team.
Maintain working knowledge of regulatory requirements as they relate to QM operations and protocols.
Complete other tasks and assignments based on department and business needs.
Demonstrate a commitment to incorporate LEAN principles into daily work.