Clinical Quality Nurse

About Our Company

At Altais, we're looking for bold and curious innovators who share our passion for enabling better health care experiences and revolutionizing the healthcare system for physicians, patients, and the clinical community. Doctors today are faced with the reality of spending more time on administrative tasks than caring for patients. Physician burnout and fatigue are an epidemic, and the healthcare experience and quality suffer as a result. At Altais, we’re building breakthrough clinical support tools, technology, and services to let doctors do what they do best: care for people. We invite you to join our growing passionate team as we change the game for the future of healthcare and enable the experience that people need and deserve.

About Your Team

Are you looking to work with a high performing, fast growing and dynamic Clinical Quality team? Altais and our subsidiaries, form one of the most recognized medical groups in California. We are 4,000+ physicians, working in over 40 cities in California, caring for more than 500,000 patients. If working in a mission driven organization supporting highly competent, hard-working, thoughtful clinicians who value good ideas and are passionate about reshaping healthcare excites you, then we are thrilled to welcome you to your new career.

This position is located in our brand-new Oakland City Center location, or remotely (within the state of California). We are flexible provided you are open to traveling to the Oakland office locations as needed.

About Your Work

The Clinical Quality Improvement Nurse is responsible for partnering with external providers across the continuum of care to enhance the overall quality of care delivered to members. Responsible for identifying, developing, coordinating, promoting, supporting, and implementing assigned Clinical Quality, and/or service improvement projects and programs, the Quality Nurse acts as a resource for evidence-based practice integration, provider training/education, policy review/development, and regulatory/accreditation interpretation. Specifically, develops targeted activities to improve performance related to CMS Star Ratings, HEDIS, CAHPS, HOS, P4P and other identified performance measures. Manages multiple complex initiatives that impact the quality or effectiveness of health care delivery and/or health care services. Acts in conjunction with both external facing and plan quality improvement leaders and key stakeholders to provide support for multi-disciplinary teams.

You will focus on

• Lead and/or participate in multi-department/cross-functional committees; including Altais and external stakeholder workgroups which support key quality improvement initiatives. This may include preparing reports, data analysis, and/or other materials for committee presentation and management.
• Utilize knowledge of clinical processes and/or hospital operations to collaboratively develop targeted activities (i.e., those based on current outcome performance and/or aligned with industry best-practices) to improve CMS Star Ratings, HEDIS, CAHPS, HOS, P4P and other identified performance measures.
• Research evidence-based practices, national and regional benchmarks, and industry standards and integrates findings into improvement initiatives.
• Perform continuous monitoring of improvement activities via routine analysis of measure outcomes.
• Analyze performance outcomes and provide meaningful feedback (i.e., specific, measurable, relevant, timely, etc.) to manager in relation to process improvement enhancements.
• Effectively utilize performance improvement methodologies to support internal quality initiatives in the development, refinement, and implementation of rapid-cycle performance improvement.
• Participate in the development and maintenance of annual quality improvement program documents and evaluations, quality incentive program audits (i.e., IHA VBP4P), policies and procedures, and improvement activities.
• Support the development, upgrade, and delivery of comprehensive quality improvement training programs and problem-solving methodologies/tools to QI teams and other stakeholders as needed in collaboration with the quality improvement team.
• Support intradepartmental quality improvement teams, programs, projects, and initiatives as assigned.
• Continuously seek to enhance delivery and efficiency of external-facing quality improvement initiatives via technological advancement and internal-facing process improvement.
• Translate data into meaningful information, draw conclusions, and relate findings to industry standards. Provide recommendations to departmental stakeholders and Quality Improvement Leadership Team regarding performance gaps, program implementation, and performance outcomes in order to maintain an effective Quality Improvement program.
• Other responsibilities include clinical assessment, member/family/caregiver education, development, and implementation of individualized care plans.
• Utilizes advanced clinical judgement and critical thinking skills to perform care Review, track, document, and manage clinical appeals and grievances.
• Collaborate with the Medical Directors to rank and respond to appeals, grievances, and Quality Issues (QIs), ensuring compliance with clinical appeal and grievance accreditation and regulatory standards.
• Review and summarize clinical appeal records for Medical Directors’ determinations.
• Collaborate with Appeals & Grievance, Clinical Oversight and Quality teams by serving as a clinical resource.
• Coordinate and cross-connect with a variety of internal departments (i.e. Medical Directorate, Care Management, Claims, Decision Support).
• Document clinical reviews, summaries and letters in care management system/tracking system.
• Assure compliance with regulatory turn-around times: Complete Standard Appeals within 25-30 calendar days / Complete Expedited Appeals within 24-72 hours.
• Collaborate with Health Plans as required to assure timely responses- to appeals and grievances.
• Participate in case conferences and provide clinical information and assessment of care.
• Apply clinical judgment to identify and coordinate referrals to appropriate departments or programs for member’s needs including Case Management, Palliative Care, Complex Case Management, Behavior Health, etc.
• Develop and conduct trainings as needed for member-facing departments.
• Participate in DHCS, DMHC, and NCQA audits and participate in correcting processes to meet audit requirements.
• Research and trouble-shoot issues related to clinical performance, quality and care management.
• Actively contribute to program and process improvements and goals.
• Participate in continuous improvement of the managed care process to prevent appeals, grievances and Quality Issues.

The Skills, Experience & Education You Bring

• California RN License
• Epic Experience is preferred
• 3 years acute clinical experience required
• 3 years utilization review/manage care experience
• 3 years experience in a clinical/health care environment with demonstrated experience at a professional level in quality improvement/clinical program oversight/project management.
• Managed care experience in medical management desirable, preferably in an HMO or IPA setting.
• Experience with ICD-9, CPT and HCPCS codes preferred
• Ability to read and understand medical records and extract data.
• Working knowledge of healthcare quality performance and measurement sets including CMS quality withhold, Managed Care Accountability Set, NCQA Quality Improvement Standards and HEDIS. Ability to apply knowledge of project management techniques, tools of continuous improvement, and work process redesign. Requires knowledge of the local healthcare market, patient demographics and needs and plan-specific information.
• Knowledge of managed care concepts, Medicare/Medi-Cal Guidelines.
• Basic computer skills including Outlook, WORD, Microsoft suite and VPN or other remote access systems. Ability to navigate through various software programs with instruction.
• With knowledge of patient’s healthcare benefits, the ability to formulate effective discharge plans and communicate them to the various stakeholders.
• Ability to identify B&T member needs, collaborate with patients and their providers to achieve optimal quality healthcare outcomes.
• Ability to think creatively and formulate innovative solutions
• Excellent communication skills, both written and verbal.
• Familiarity with SBAR form of communication is desired.
• Excellent organizational skills.
• Ability to set priorities and be highly productive, work well under pressure.
• Complies with policies and procedures.
• Maintains confidentiality of medical, product and company information.
• Performs job safely with respect to others, to property and individual safety; works effectively with others to encourage teamwork and productivity.
• Maintains strict confidentiality of client information; does not discuss internal business with external entities.

You Share our Mission & Values

• You are passionate about improving the healthcare experience and want to be part of the Altais mission.
• You are bold and curious- willing to take risks, try new things and be creative.
• You take pride in your work and are accountable for the quality of everything you do, holding yourself and others to a high standard.
• You are compassionate and are known as someone who demonstrates emotional intelligence, considers others when making decisions and always tries to do the right thing.
• You co-create, knowing that we can be better as a team than individuals. You work well with others, collaborating and valuing diversity of thought and perspective.

You Share Our Mission & Values:

• You are passionate about improving the healthcare experience and want to be part of the Altais mission.
• You are bold and curious- willing to take risks, try new things and be creative.
• You take pride in your work and are accountable for the quality of everything you do, holding yourself and others to a high standard.
• You are compassionate and are known as someone who demonstrates emotional intelligence, considers others when making decisions and always tries to do the right thing.
• You co-create, knowing that we can be better as a team than individuals. You work well with others, collaborating and valuing diversity of thought and perspective.
• You build trust with your colleagues and customers by demonstrating that you are someone who values honesty and transparency.

Altais values the contribution each Team Member brings to our organization. Final determination of a successful candidate’s starting pay will vary based on several factors, including, but not limited to education and experience within the job or the industry. The pay scale listed for this position is generally for candidates that meet the specified qualifications and requirements listed on this job description. Additional pay may be determined for those candidates that exceed these specified qualifications and requirements. We provide a competitive compensation package that recognizes your experience, credentials, and education alongside a robust benefits program to meet your needs.

The anticipated pay range for this role is listed in our salary posting for transparency but may vary based on factors including the candidate’s qualifications, skills, experience, and geographic location. This base pay range is specific to California and can vary based on Bay Area, Metro LA, and Greater California regions which may not be applicable to other locations.

Altais and its subsidiaries and affiliates are committed to protecting the privacy and security of the personal information you provide to us. Please refer to our ‘CPRA Privacy Notice for California Employees and Applicants’ to learn how we collect and process your personal information when you apply for a role with us.

Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork – Activity level: Sedentary, frequency most of workday.

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.