Quality Review Nurse, Rn 23-01200

Position
Quality Review Nurse, RN
Description
Reporting to the Manager of Provider Quality Oversight, the Provider Quality Review Nurse, RN is responsible for:
- Receive and research all PQI and QR cases as assigned, provide a summary and recommendations to the Medical Director of case assignments.
- Effectuate all action items as determined by the Medical Director to resolution of case assignments.
- Reviewing escalated issues
- Discussing, and reviewing cases with Medical Directors referred to the Quality Management (QM) department.
- Investigation of cases includes, but not limited to, the documentation of case summaries, follow up actions, outreach efforts, and communications in the QM database.

1. Investigate and complete case summaries and make recommendations for any Potential Quality of Care Incidents (PQI) referred to the QM department.
2. Maintain direct communication with departments, external facilities including hospitals, Skilled Nursing Facilities, and/or Providers to ensure all PQI issues are thoroughly investigated, and care is coordinated in a timely manner, as needed.
3. Review requested medical records to ensure complete case documentation is received from all practitioners, providers, and entities/agencies to ensure thorough investigation of the issue.
4. Review case findings and recommendations with Medical Director. Issue Corrective Action Plans (CAP), review CAP responses, draft Opportunity for Improvement letters, and coordinate other interventions as needed to ensure all issues were addressed and future occurrences of the same issue are mitigated.
5. Complete data entry into database systems, maintain updated documentation and other tracking mechanisms for all cases.
6. Review and execute ad hoc requests, Quality Reviews, and/or focused audits, as needed.
7. Escalate issues of non-compliance to the Quality Systems Management team.
8. Maintain working knowledge of regulatory requirements as they relate to QM operations and protocols.
9. Complete other tasks and assignments based on department and business needs.
10. Demonstrate a commitment to incorporate LEAN principles into daily work.

Requirements

• Three (3) or more years of any individual or combined healthcare experience in quality assurance, quality management, quality improvement, utilization management, discharge planning, and/or case management. Three (3) or more years of work experience in a managed care, hospital, provider practice, or other comparable healthcare experience
• Experience preferably in a quality/performance improvement setting.
• Bachelor's degree in Nursing from an accredited institution required.
• In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above.
• Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Clinical certification in area specialty) preferred.
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.
• Yes, must have a valid California Driver's License.
• Excellent understanding of performance improvement, quality assurance, and utilization management. Knowledgeable in clinical analysis of health records, assessing or evaluating quality, and identifying problems or issues with care delivery.
• Microcomputer applications: spreadsheet, database, and word processing. Excellent written and verbal communication skills. Excellent coordination skills. Ability to communicate findings and form recommendations based on clinical case reviews.

Additional information

• Remote

INDH