Quality Review RN - Clinic: Hoag Clinic Clinical Services
About The Position
The Quality Management (QM) Nurse is responsible for preparing, reviewing, and presenting findings on all potential quality management events reported to the department and all grievances submitted to the Medical Director, Health Plan (HP) and/or Quality Management Committee (QMC) based upon department policies and procedures. Depending on each Health Plan’s reporting requirements, the QM Nurse reviews all submitted grievances, supporting documentation and prepares a response to the Health Plan partners for their review and determination. The QM Nurse tracks the activities related to the grievance until the Health Plan releases a final determination. The QM Nurse documents all activities in the Quality Management System for monitoring and Committee reporting. The QM Nurse participates in any quality management projects as assigned. The QM Nurse assists in the coordination and collection of HEDIS medical records, identifies potential gaps in care/quality of care, provides recommendations to the committee on resolving gaps identified and conducts assigned department audits as appropriate. The role involves a high level of data collection, intensive patient care review, and implementing process improvement activities. This position participates in the QMC by providing the QM activity reports to the committee. Other duties as assigned.
Requirements
- At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
- Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards.
- Must have 2 to 3 years of Quality or Peer review responsibility.
- Registered Nurse (RN) in the State of California
Nice To Haves
- Bachelor’s degree in a health care related field preferred.
Responsibilities
- Preparing, reviewing, and presenting findings on potential quality management events
- Reviewing grievances and preparing responses to Health Plan partners
- Tracking activities related to grievances
- Documenting activities in the Quality Management System
- Participating in quality management projects
- Assisting in the coordination and collection of HEDIS medical records
- Identifying potential gaps in care/quality of care
- Providing recommendations on resolving gaps identified
- Conducting assigned department audits
- Providing QM activity reports to the committee
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What This Job Offers
Career Level
Mid Level
