Quality Review RN : Hospice

Hoag•Newport Beach, CA

11d

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.
2 to 3 years of Quality or Peer review responsibility.
Registered Nurse (RN) in the State of California License

Nice To Haves

Bachelor’s degree in a health care related field

Responsibilities

Prepare, review, and present findings on all potential quality management events.
Review all grievances submitted to the Medical Director, Health Plan (HP) and/or Quality Management Committee (QMC).
Prepare responses to Health Plan partners for review and determination based on submitted grievances and supporting documentation.
Track activities related to grievances until a final determination is released by the Health Plan.
Document all activities in the Quality Management System for monitoring and Committee reporting.
Participate in quality management projects as assigned.
Assist in the coordination and collection of HEDIS medical records.
Identify potential gaps in care/quality of care.
Provide recommendations to the committee on resolving identified gaps.
Conduct assigned department audits as appropriate.
Participate in the QMC by providing QM activity reports to the committee.