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
- 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.
- 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!