Quality Assurance/Continuous Improvement Nurse, RN

IEHP•California, MD

49d•Remote

About The Position

Reporting to the Grievance & Appeals (G&A) Quality Supervisor, the G&A Quality Assurance/Continuous Improvement (QA/CI) Nurse, RN is responsible for ensuring the highest quality processes and activities are performed by the G&A clinical staff. Per regulatory requirements, the G&A QA/CI Nurse, RN will assist in the development of quality initiatives and develop & implement the clinical QA Plan. This position performs standardized monitoring and auditing within the G&A department; including all case types: Appeals, Grievances, DMHC cases (Consumer Complaints and Independent Medical Reviews), regulatory and state fair hearing cases. The incumbent develops and utilizes quality auditing tools, summarizes audit findings, and assists leadership in identifying training needs for the G&A clinical staff. Identify Continuous Improvement opportunities through QA and LEAN activities. Ensure compliance with regulatory standards, practices, and guidelines in conjunction with G&A Regulatory Management. Lead and track Continuous improvement projects within the department. The G&A Quality Assurance/Continuous Improvement (QA/CI) RN will support quality assurance efforts related to appropriate Grievance case categorization to include of Quality of Care, identification of Member harm, completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS). 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

Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting
Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting
Two (2) or more years of experience relevant to Grievance & Appeals case review
Associate's degree in nursing from an accredited institution required
Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required
Thorough knowledge of: Outside agencies and resources such as CCS, CMS, DMHC, or DHCS
Thorough knowledge of: Patient rights and ethical decision-making frameworks
Thorough knowledge of: Medical necessity and level of care, chronic disease, and complex clinical cases
Thorough knowledge of: Diagnostic and procedural understanding in a clinical setting
Thorough knowledge of: Regulatory guidelines surrounding Grievances and Appeals per CMS, DHCS, and DMHC and NCQA
Microcomputer applications: spreadsheet, database, and word processing; Excellent interpersonal and communication skills
Time management and priority setting skills
Proven ability to: Demonstrate a commitment to incorporate LEAN principles into daily work
Proven ability to: Work effectively with various internal departments and external Providers and entities
Proven ability to: Establish and maintain effective working relationships with others throughout an organization
Proven ability to: Assess complex Grievance & Appeal cases and recommend appropriate action
Proven ability to: Analyze documentation of incoming cases to determine appropriateness of care and applicable next steps
Proven ability to: Effectively escalate issues as identified, following established protocols
Proven ability to: Maintain a positive attitude and work in a team setting
Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire
While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell
The employee must occasionally lift or move up to 25 pounds
Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus

Nice To Haves

Bachelor's degree in nursing from an accredited institution preferred

Responsibilities

Assist in the development of quality initiatives
Develop & implement the clinical QA Plan
Perform standardized monitoring and auditing within the G&A department
Develop and utilize quality auditing tools
Summarize audit findings
Assist leadership in identifying training needs for the G&A clinical staff
Identify Continuous Improvement opportunities through QA and LEAN activities
Ensure compliance with regulatory standards, practices, and guidelines in conjunction with G&A Regulatory Management
Lead and track Continuous improvement projects within the department
Support quality assurance efforts related to appropriate Grievance case categorization to include of Quality of Care, identification of Member harm, completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS)