Job Description

Quality Assurance/Continuous Improvement Nurse, RN Reporting to the Grievance & Appeals (G&A) Quality Supervisor, the G&A Quality Assurance/Continuous Improvement (QA/CI) Nurse, RN is responsible for ensuring the highest quality processes and activities are performed by the G&A clinical staff. Per regulatory requirements, the G&A QA/CI Nurse, RN will assist in the development of quality initiatives and develop & implement the clinical QA Plan. This position performs standardized monitoring and auditing within the G&A department; including all case types: Appeals, Grievances, DMHC cases (Consumer Complaints and Independent Medical Reviews), regulatory and state fair hearing cases. The incumbent develops and utilizes quality auditing tools, summarizes audit findings, and assists leadership in identifying training needs for the G&A clinical staff. Identify Continuous Improvement opportunities through QA and LEAN activities. Ensure compliance with regulatory standards, practices, and guidelines in conjunction with G&A Regulatory Management. Lead and track Continuous improvement projects within the department. The G&A Quality Assurance/Continuous Improvement (QA/CI) RN will support quality assurance efforts related to appropriate Grievance case categorization to include of Quality of Care, identification of Member harm, completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS). What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience. Reporting to the Grievance & Appeals (G&A) Quality Supervisor, the G&A QA/CI Nurse, RN is responsible for ensuring high quality processes and activities are performed by the G&A clinical staff. Per regulatory requirements, the QA/CI Nurse will assist in the development of quality initiatives and implement the clinical QA Plan. This position performs standardized monitoring and auditing within the G&A department across all case types: Appeals, Grievances, DMHC cases (Consumer Complaints and Independent Medical Reviews), regulatory and state fair hearing cases. The incumbent develops and utilizes quality auditing tools, summarizes audit findings, and assists leadership in identifying training needs for the G&A clinical staff. Identify Continuous Improvement opportunities through QA and LEAN activities. Ensure compliance with regulatory standards, practices, and guidelines in conjunction with G&A Regulatory Management. Lead and track Continuous improvement projects within the department. The G&A QA/CI RN will support quality assurance efforts related to appropriate Grievance case categorization to include Quality of Care, identification of Member harm, and reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS). Commitment to Quality: The IEHP Team is committed to incorporating IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks Competitive salary Telecommute schedule CalPERS retirement State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account – Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Education & Requirements Two (2) or more years of experience as an RN in case management, utilization management in a managed care setting or related experience in a health care delivery setting Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting Two (2) or more years of experience relevant to Grievance & Appeals case review Associate’s degree in nursing from an accredited institution required Bachelor’s degree in nursing from an accredited institution preferred Active, unrestricted RN license issued by the California Board of Registered Nursing required Key Qualifications Thorough knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS Knowledge of patient rights and ethical decision-making frameworks Knowledge of medical necessity and level of care, chronic disease, and complex clinical cases Diagnostic and procedural understanding in a clinical setting Regulatory guidelines surrounding Grievances and Appeals per CMS, DHCS, DMHC and NCQA Proficiency with microcomputer applications (spreadsheets, databases, word processing); strong interpersonal and communication skills Time management and priority setting skills Demonstrated ability to incorporate LEAN principles into daily work Ability to work with various internal departments and external Providers and entities Ability to establish and maintain effective working relationships Ability to assess complex Grievance & Appeal cases and recommend appropriate action Ability to analyze documentation of incoming cases to determine appropriateness of care and next steps Ability to escalate issues following established protocols Positive attitude and teamwork orientation Word processing and data entry; willingness to travel within the Inland Empire Physical ability to perform duties as described (standing, walking, sitting, using hands, reaching, climbing stairs, etc.) Ability to lift or move up to 25 pounds occasionally Vision requirements including close, distance, color, peripheral, depth perception, and focus adjustment Compensation Pay Range: $91,249.60 USD Annually - $120,910.40 USD Annually Start your journey towards a thriving future with IEHP and apply TODAY! #J-18808-Ljbffr IEHP

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