Quality Investigator

Partnership HealthPlan of California•Fairfield, CA

About The Position

Overview To work with a dedicated and committed team, the RN Quality Investigator I is responsible forassessing and improving the quality of care provided by the providers serving our members. Responsibilities Potential Quality Issue Investigation and Resolution Reviews potential quality issues that are referred to the QI department, including a reviewof allegations/complaints from members and providers that present adverse variation fromexpected clinician performance, clinical care, or outcome of care, otherwise known asPotential Quality Issues (PQIs). Conducts a thorough internal investigation of PQIs (provider performance and/or systemissues), including a review of the incident as reported or alleged, including a review of allrelevant medical records. Obtain responses from provider(s) and appropriate Partnership departments. Whenappropriate, generate letters to the providers of concern requesting deliberated responsesand additional documentation, if indicated. Presents a summary of each case at internal PQI team rounds for a secondary review by theCMO or Medical Directors. Works collaboratively with the CMO/Medical Directors in the investigation of potentialProvider Preventable Conditions (PPCs) and ensures that appropriate notification is sentto 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 specialtyphysician or by a Subject-Matter-Experts (SME), the RN Quality Investigator follows theprocess of requesting investigational review and responses from the SME. Peer Review Committee Ensures that case files selected for review at the Peer Review Committee meeting arecomplete, with all required documentation available for review. Actively participates in case discussions and provides additional information asneeded. Refers cases to the Credentialing Committee as recommended by the Peer ReviewCommittee. Assists the CMO/.Medical Directors in Focus Review activities as determined by the PeerReview Committee or Partnership policy. Generates a request for a Corrective Action Plan as recommended by the Peer ReviewCommittee and performs follow-up with the provider to ensure the CAP is implementedand completed. Generates a case closure letter to the provider or facility when appropriate. Documentation Ensures that PQI cases are processed and closed to completion within the specifiedtimeframe. Ensures that cases are documented in the PQI database SUGARCRM, and all hard copyrelated documentation is kept in a secure file cabinet in the QI department where onlydesignated personnel have access to these files. Participates in the Inter-Rater Reliability (IRR) process to ensure cases are appropriatelyreviewed and to ensure that the reliability of the PQI case review process can be evaluated. Track and Trend Reporting Provides feedback on identified trends and other data in support of the Member SafetyQuality Investigations team reporting to Internal Quality Improvement (IQI) and QualityUtilization Advisory Committee (QUAC), as well as to the Department of Health CareServices (DHCS). Secondary Duties and Responsibilities Assists in the identification and recommendation of appropriate interventions inQI 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 andMedicaid Services (CMS) and the California Department of Health Care Services (DHCS)requirements and health plans’ compliance related to Quality Measurement andImprovement, Site Review, Peer Review, and Credentialing. Collects, coordinates and monitors QI activities that affect other departments within thehealth plan. These include credentialing information, member complaints, appeals andgrievances, collection and investigation of Potential Quality Issues, and Peer ReviewCommittee case determinations. Participates on improvement teams as assigned by the Member Safety Team Manager,Department Director, Senior Director of Quality and Performance Improvement, orCMO.

Requirements

BSN or Bachelor’s degree in an applicable field, minimum three (3)years clinical experience. Experience in quality improvement orquality management, managed care; facility site review; HEDIS andTitle 22 preferred.
Current California Registered Nurse license required.
Knowledge ofhealthcare total quality management theory, practices, standards andapplicable laws and the ability to access data and information usingelectronic record systems required.
Valid California Driver's licenserequired.
Proficiency in MS Word and Excel.
Excellent oral and writtencommunication skills.
Ability to facilitate groups and tasks.
Excellentplanning and organizational skills.
Efficient; follows through oncommitments.
Attention to detail.
Flexible and adaptable tocompeting priorities, strong team player and able to remain calm underpressure.

Nice To Haves

Experience in quality improvement orquality management, managed care; facility site review; HEDIS andTitle 22 preferred.
Knowledge of NCQA/HEDIS standards.
Familiarity withbusiness practices and protocols preferred.

Responsibilities

Reviews potential quality issues that are referred to the QI department, including a reviewof allegations/complaints from members and providers that present adverse variation fromexpected clinician performance, clinical care, or outcome of care, otherwise known asPotential Quality Issues (PQIs).
Conducts a thorough internal investigation of PQIs (provider performance and/or systemissues), including a review of the incident as reported or alleged, including a review of allrelevant medical records.
Obtain responses from provider(s) and appropriate Partnership departments. Whenappropriate, generate letters to the providers of concern requesting deliberated responsesand additional documentation, if indicated.
Presents a summary of each case at internal PQI team rounds for a secondary review by theCMO or Medical Directors.
Works collaboratively with the CMO/Medical Directors in the investigation of potentialProvider Preventable Conditions (PPCs) and ensures that appropriate notification is sentto 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 specialtyphysician or by a Subject-Matter-Experts (SME), the RN Quality Investigator follows theprocess of requesting investigational review and responses from the SME.
Ensures that case files selected for review at the Peer Review Committee meeting arecomplete, with all required documentation available for review.
Actively participates in case discussions and provides additional information asneeded.
Refers cases to the Credentialing Committee as recommended by the Peer ReviewCommittee.
Assists the CMO/.Medical Directors in Focus Review activities as determined by the PeerReview Committee or Partnership policy.
Generates a request for a Corrective Action Plan as recommended by the Peer ReviewCommittee and performs follow-up with the provider to ensure the CAP is implementedand 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 specifiedtimeframe.
Ensures that cases are documented in the PQI database SUGARCRM, and all hard copyrelated documentation is kept in a secure file cabinet in the QI department where onlydesignated personnel have access to these files.
Participates in the Inter-Rater Reliability (IRR) process to ensure cases are appropriatelyreviewed 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 SafetyQuality Investigations team reporting to Internal Quality Improvement (IQI) and QualityUtilization Advisory Committee (QUAC), as well as to the Department of Health CareServices (DHCS).
Assists in the identification and recommendation of appropriate interventions inQI 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 andMedicaid Services (CMS) and the California Department of Health Care Services (DHCS)requirements and health plans’ compliance related to Quality Measurement andImprovement, Site Review, Peer Review, and Credentialing.
Collects, coordinates and monitors QI activities that affect other departments within thehealth plan. These include credentialing information, member complaints, appeals andgrievances, collection and investigation of Potential Quality Issues, and Peer ReviewCommittee case determinations.
Participates on improvement teams as assigned by the Member Safety Team Manager,Department Director, Senior Director of Quality and Performance Improvement, orCMO.