Clinical Quality Review Registered Nurse - RN

Clinical Quality Review RN

This role is starting out remote for the time being however, candidates must still be local to the Woodland Hills office. This is a contract to hire opportunity with a large healthcare insurance company. Please apply with your updated resume to be considered.

Pay: $45.00 - $47.00/ hour

Schedule: Mon - Fri 8:00am - 4:30pm

Details:

• Investigates and reviews potential quality of care issue (PQI) allegations or concerns arising from member grievances and internal referrals
• Prepares cases on-line using department database per departmental protocols. Case assignments may range from routine to complex in scope.
• Presents PQI case review summaries/findings to Medical Director at weekly Case Review Meetings.
• Prepares and follows case for subsequent multi-level reviews as needed. This may include a specialty reviewer, Peer Review Committee (PRC) or Credentialing Committee.
• Drafts corrective action plan (CAP) requests and educational letters for Medical Director to be sent to providers based on quality findings. Presents CAP responses to Medical Director and/or PRC.

Qualifications:

• Active and unrestricted California RN License required
• 3-5+ years hands-on clinical nursing experience across a variety of specialties required
• Strong investigative, problem solving, critical thinking and clinical assessment skills with ability to identify possible quality of care issues
• Quality management, risk management, peer review, grievance review or equivalent experience required
• Experience or strong working knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) and managed care/various lines of business (HMO, PPO, Medicare, Medi-Cal, Cal MediConnect)
• Strong verbal/written communication and organizational skills
• Proficiency in use of PC-based software programs including Microsoft Word, Excel, PowerPoint and Outlook with strong typing skills required
• Ability to work independently in a fast-paced and fluid work environment
• Bachelor’s degree in Nursing/equivalent or advanced degree

Apply today with your updated resume!