Quality Program Nurse, RN (Remote with field work)

Inland Empire Health Plan•, CA

5d•$91,250 - $120,910•Hybrid

About The Position

Under the direction of the Manager, Quality Management Nurses, Quality Program Nurses (QPN) are responsible for the implementation of Quality Management policies, procedures, and activities. QPN’s enforce DHCS regulatory requirements as pertaining to Facility Site Review (FSR) and Medical Record Review (MRR) criteria. 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 experience in Quality Assurance, Utilization Management, Case Management, provider liaison duties, and/or clinical experience in a hospital/clinical setting
Experience preferably in an HMO or Managed Care setting
Associate’s degree in Nursing from an accredited institution required
Possession of an Active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required
Valid State of California driver's license and valid automobile insurance
Knowledgeable and understanding of nursing principles & evidence based practices
Computer applications: spreadsheet, database, and word processing.
Strong organizational, time-management, and critical thinking skills
Excellent written and verbal communication and interpersonal skills.
Highly skilled in interpersonal communication, including conflict resolution.
Ability to manage multiple projects with competing deadlines and changing priorities

Nice To Haves

Bachelor’s degree in Nursing from an accredited institution preferred
Possession of valid Certified Site Reviewer Certificate issued from DHCS or participating Medi-Cal Managed Health Plan Provider
If not a CSR, the candidate should be willing and able to get certified within 6 months of hire

Responsibilities

Perform initial, periodic, and verification Site Review and Medical Record Surveys for assigned Primary Care Providers. Conduct other regulatory audits as assigned.
Review Primary Care Provider Corrective Action Plans (CAP) submissions and monitor CAP compliance.
Perform focused audits as directed by IEHP Subcommittees.
Perform annual HEDIS data abstractions.
Monitor assigned PCPs for potential problem hours and document findings.
Review QM reports and CAP log on a weekly basis. Responsible for Provider compliance and follow up.
Attendance and participation in Quality Management Committee and/or Subcommittee meetings, as needed.
Attend Site Review and Medical Record Survey training, as mandated by DHCS, to maintain and become a Certified Site Reviewer.
Attendance and participation in Quality Management, Medical Services, and other inter-departmental staff meetings as indicated.
Attendance and participation in Quality Management Committee or Subcommittee meetings, as directed.
Any other duties as required to ensure Plan operations are successful.