Quality Analyst LVN - Quality Management - SCMG - Days

Sharp HealthCare•San Diego, CA

8d•Onsite

About The Position

Under the direction of the UM Supervisor, utilizes critical thinking and clinical expertise in various quality improvement activities. Supports the Sharp Community Medical Group Quality Management and Utilization Management Programs, through quality of care reviews, complaint and dismissal investigations, clinical appeal coordination, data collection and measurement, analysis and interpretation, and evaluation and reporting of key performance measures and improvement activities. Additionally, the Quality Analyst LVN acts upon opportunities of improvement and maintains the department processes in compliance with State and Federal Standards.

Requirements

2 Years Clinical experience in the patient care setting (experience in both acute and ambulatory care preferred)
California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED

Nice To Haves

Bachelor's Degree
Related field
Experience in both acute and ambulatory care
1 Year Utilization Management/Case Management/Quality Management experience
Expertise in Lean Six Sigma or Continuous Quality Improvement (CQI) helpful.

Responsibilities

Analyzes and prepares data
Provides documentation and statistics as requested by Supervisor or Manager.
Utilizes departmental databases and computer software programs, i.e. IDX Customer Service Module, Microsoft Word/Excel/Access/Power Point, and other programs to collect and analyze data, produce accurate reports, identify and report trends.
Prepares documentation for review and discussion at the SCMG UMC/QOC Committees as requested by Supervisor or Manger. Such documentation could include policies and procedures, quality activities, peer review and re-credentialing reports.
Provides assistance with goal setting, reporting and evaluation for applicable quality activities (i.e.: ICE Annual work plan, health plan reporting).
Facilitates and coordinates clinical appeals processes to meet SCMG, health plan, and regulatory requirements in a timely, efficient manner utilizing clinical knowledge and strong communication and problem solving skills.
Collaborates with the provider offices, the health plans, other SCMG departments/staff and Medical Directors.
Reviews, investigates, and responds to clinical appeal inquiries received from contracted health plans in strict accordance with the health plan appeals policies and timeliness standards.
Maintains accurate, timely documentation of clinical appeals inquiries and accesses computer systems, i.e. IDX Referral Module or Customer Service Module, to research and document appeals related activities.
Serves as a liaison/resource for other HSM departments, and Customer Service department on appeals issues.
Assists in identifying learning needs and the ongoing education of SCMG staff, providers, physicians and their office staff.
Utilizes systems to inform/monitor staff compliance with regulatory and accreditation standards.
Processes appeals, overturn timely and accurately according to healthplan requirements and department guidelines.
Maintains the Quality and Utilization Management policies and procedures by updating information according to department guidelines and regulatory and compliance requirements.
Reviews compliance with health plan requirements at least annually in preparation for upcoming Utilization Management audits and coordinates changes in internal processes to ensure compliance.
Acts upon health plan audit results in conjunction with Quality Supervisor or Department Manager.
Maintains the UM SharePoint site for the UM Department, adding new content/areas and creating back-ups per department guidelines.
Performs other duties as requested. These may include, but are not limited to: workgroups, survey, audits, and back-up support for others.
Receives and coordinates requests for PCP transfers and member dismissals through collaboration with the provider offices, the health plans, other SCMG departments, and the Health Services Management Staff in an effective and efficient manner.
Maintains accurate and confidential documentation related to member counseling and dismissals and responds appropriately and timely to SCMG staff, practitioner and health plan requests and inquiries.
Coordinates communication with SCMG practitioner offices and SCMG Case Managers to prepare correspondence to members, health plans, and practitioners.
Utilizes computer databases and spreadsheets to track and trend member dismissals in order to identify and report adverse or aberrant trends.
Demonstrates courteous, professional, and cooperative demeanor toward coworkers, patients, physician, and health plan contacts.
Demonstrates dependability as evidenced by punctuality, timeliness of reports, and timely notification to supervisor of deviation from schedule hours.
Performs other duties or such as special projects when assigned and provides back up for other department staff as deemed necessary by the Manager or Supervisor.
Accepts work readily and completes work within specified timeframes.
Keeps Supervisor and co-workers advised of progress.
Receives and investigates quality variance events, member grievances or other quality related issues through collaboration with the provider offices, the health plans, other SCMG Departments, and the Health Services Management Staff.
Maintains accurate and confidential documentation related to quality variance events, member grievances, or other quality related issues and responds appropriately and timely to health plan requests and inquiries.
Utilizes computer databases and spreadsheets to track and trend data from quality variance events, grievances, or other quality related issues in order to identify and report adverse or aberrant trends.
Accesses existing computer systems, i.e. IDX Referral Module, Customer Service Module, and OnBase, to research and document quality variance events, grievances, or other quality related issues.
Utilizing Utilization Management reports, performs internal audits for SCMG and Partner organization on the various UM activities as assigned by Department Supervisor or Manager.
Participates in ICE and other accreditation organizations and acts upon information provided to ensure SCMG's compliance.
Keeps current knowledge and understanding of applicable health plans, accreditation, and regulatory requirements related to managed care and assigned job responsibilities.
Coordinates site audits for quality issues/grievances to support compliance with regulatory requirements and credentialing/recredentialing activity.
Actively participates in process improvement activities in the department and assigned by the Quality Supervisor or Department Manager.
Seeks direction from Supervisor or Department Manager for instances that do not fall under a defined process.