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Form of workJob Description
Openings for both a Quality Compliance Nurse and a Compliance Coordinator.
QUALITY COMPLIANCE NURSE
PURPOSE:
The Quality and Compliance Nurse is responsible for working with the Medical Director, the VP of Clinical Policy, the QM Committee in developing, implementing, and refining the Quality Management Program. They are also responsible for oversight and management of Health Plan Audits, as well as responding to Appeals and Grievances.
ESSENTIAL DUTIES:
- Organizes and participates in QM Committee meetings. Prepares agenda and meeting minutes. Provides support functions necessary for effective QM Committee processes.
- Helps in the development and maintenance of the QM Plan, annual work plan and quarterly reports in conjunction with the QM Committee.
- In collaboration with VP of Clinical Policy and Client Health Services Department, identifies quality standards and clinical benchmarks.
- As part of quarterly reporting, establishes QM processes through tracking and trending of data for identification of under and over utilization.
- Coordinates QM functions between Medical Management Department, Physician Group, Health Plan and outpatient care settings assuring quality improvement in clinical care and non-clinical aspects of service.
- Provides oversight and management of Health Plan audits including the preparation of all needed documents
- Timely review and processing of appeals and UM department grievances according to Medical Management policies and procedures.
- Develops and monitors compliance with responses to corrective action plans (CAP) for post health plan audits and regulatory audits.
- Acts as liaison to all affiliated health plans.
COMPLIANCE COORDINATOR
The Compliance Coordinator is responsible for supporting the Quality Compliance Nurses for audit preparation. This includes review of audit tool, requesting authorization universes and file preparation for audit submission.
Thrifty Management Services is the dedicated MSO for Preferred IPA of California, providing the best possible care management, care coordination, and claims processing services to Preferred IPA and their members. We work with the network’s participating physicians to coordinate patient care when a referral is made to a specialist or hospital for diagnosis and treatment. We coordinate patient care across all aspects of the provider network. We provide high quality services to its participating physicians and superior health care to its members.
