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Quality Review/Management Senior- 24670-1 WDH/ELS
Woodland Hills, California | Contract
EXCITING CONTRACT OPPORTUNITY FOR RN!
THIS POSITION CAN EITHER SIT IN WOODLAND HILLS OR EL SEGUNDO. THERE IS NO OPPORTUNITY FOR REMOTE! THERE IS A CHANCE IT MAY BECOME A TEMP TO PERM POSITION.
Clinical Quality Review (CQR) Department investigates and reviews potential quality of care issues (PQIs) arising from member grievances and internal referrals. This refers to quality of care issues which have the potential to result in harm or actually resulted in harm to the member including serious or life threatening issues. CQR identifies opportunities for improvement when contracted providers exhibit patterns of substandard practice or practices which are not within the framework of accepted community standards.
RN Reviewer Responsibilities:
- Analyzes potential quality issues from both internal and external sources. Obtains additional clinical information and performs pertinent research of company systems, disease processes, etc. as needed. Once all information is gathered and organized, prepares written summary of pertinent clinical documentation and determines review level based on findings. If reviewed at RN level, records rationale for leveling and prepares brief case notes for Medical Director (MD) oversight. If MD level review needed, records rationale for next level review and refers case based on CQR protocols. Multi-level reviews can include escalation to Specialty Reviewer, Peer Review Committee (PRC) or Credentialing Committee.
- Prepares corrective action plan (CAP) requests and educational letters to be sent to providers based on quality findings; presents CAP responses to Medical Director/PRC.
- Gives verbal case presentations to Medical Director and clinical staff during regularly scheduled Clinical Case Review Meetings.
- Performs special projects as assigned.
- Participates in regulatory audits as assigned.
Key attributes for an individual to be successful in this position:
- Strong investigative, problem solving, critical thinking and clinical assessment skills and ability to identify possible deviations from standard of care
- Highly motivated
- Ability to work independently
- Action/results oriented
- Strong verbal/written communication skills.
- Strong organizational skills
- Current unrestricted CA RN License required
- Bachelor’ s degree in Nursing/equivalent preferred
- Generally requires moderate to extensive clinical acute care experience (3-5 years)
- Quality management/peer review experience and CPHQ certification preferred
- Managed care experience, i.e. broad knowledge of current concepts, practices and procedures within the health care field, especially related to HMO preferred
- Proficient in typing skills and in use of PC-based software programs including Microsoft Word and Excel
- Working knowledge of regulatory agencies and state/federal regulations (DMHC, CMS, NCQA)