Quality Investigator - Registered Nurse

Partnership HealthPlan of California•Fairfield, CA

15d•$103,060 - $133,978

About The Position

To work with a dedicated and committed team, the RN Quality Investigator I is responsible for assessing and improving the quality of care provided by the providers serving our members.

Requirements

BSN or Bachelor’s degree in an applicable field, minimum three (3) years clinical experience.
Current California Registered Nurse license required.
Knowledge of healthcare total quality management theory, practices, standards and applicable laws and the ability to access data and information using electronic record systems required.
Valid California Driver's license required.
Proficiency in MS Word and Excel.
Excellent oral and written communication skills.
Ability to facilitate groups and tasks.
Excellent planning and organizational skills.
Efficient; follows through on commitments.
Attention to detail.
Flexible and adaptable to competing priorities, strong team player and able to remain calm under pressure.
Must be able to work in a fast-paced environment and maintain courtesy and composure when dealing with internal and external customers:
Ability to prioritize workload and initiate action.
Ability to function effectively with frequent interruptions and directions from multiple team members.
Must be able to move, lift or carry objects varying in size, weighing up to 25 lbs.
Must be able to operate a vehicle used for company business.
All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

Nice To Haves

Experience in quality improvement or quality management, managed care; facility site review; HEDIS and Title 22 preferred.
Knowledge of NCQA/HEDIS standards.
Familiarity with business practices and protocols preferred.

Responsibilities

Reviews potential quality issues that are referred to the QI department, including a review of allegations/complaints from members and providers that present adverse variation from expected clinician performance, clinical care, or outcome of care, otherwise known as Potential Quality Issues (PQIs).
Conducts a thorough internal investigation of PQIs (provider performance and/or system issues), including a review of the incident as reported or alleged, including a review of all relevant medical records.
Obtain responses from provider(s) and appropriate Partnership departments.
When appropriate, generate letters to the providers of concern requesting deliberated responses and additional documentation, if indicated.
Presents a summary of each case at internal PQI team rounds for a secondary review by the CMO or Medical Directors.
Works collaboratively with the CMO/Medical Directors in the investigation of potential Provider Preventable Conditions (PPCs) and ensures that appropriate notification is sent to appropriate Partnership departments and DHCS Audits & Investigations Unit (A&I).
Notifies the provider of the result of the potential PPC clinical investigation.
Upon determination that a PQI case requires a second opinion review by a specialty physician or by a Subject-Matter-Experts (SME), the RN Quality Investigator follows the process of requesting investigational review and responses from the SME.
Ensures that case files selected for review at the Peer Review Committee meeting are complete, with all required documentation available for review.
Actively participates in case discussions and provides additional information as needed.
Refers cases to the Credentialing Committee as recommended by the Peer Review Committee.
Assists the CMO/.Medical Directors in Focus Review activities as determined by the Peer Review Committee or Partnership policy.
Generates a request for a Corrective Action Plan as recommended by the Peer Review Committee and performs follow-up with the provider to ensure the CAP is implemented and completed.
Generates a case closure letter to the provider or facility when appropriate.
Ensures that PQI cases are processed and closed to completion within the specified timeframe.
Ensures that cases are documented in the PQI database SUGARCRM, and all hard copy related documentation is kept in a secure file cabinet in the QI department where only designated personnel have access to these files.
Participates in the Inter-Rater Reliability (IRR) process to ensure cases are appropriately reviewed and to ensure that the reliability of the PQI case review process can be evaluated.
Provides feedback on identified trends and other data in support of the Member Safety Quality Investigations team reporting to Internal Quality Improvement (IQI) and Quality Utilization Advisory Committee (QUAC), as well as to the Department of Health Care Services (DHCS).
Assists in the identification and recommendation of appropriate interventions in QI activities
Provides clinical support to the Project Coordinators, and/or Analytical staff
Participates in HEDIS and other special projects and assignments as required.
Educates health plan staff on aspects of quality improvement.
Maintains current knowledge of NCQA accreditation, the US Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Services (DHCS) requirements and health plans’ compliance related to Quality Measurement and Improvement, Site Review, Peer Review, and Credentialing.
Collects, coordinates and monitors QI activities that affect other departments within the health plan. These include credentialing information, member complaints, appeals and grievances, collection and investigation of Potential Quality Issues, and Peer Review Committee case determinations.
Participates on improvement teams as assigned by the Member Safety Team Manager, Department Director, Senior Director of Quality and Performance Improvement, or CMO.