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Registered Nurse - Quality Review/Management Senior
Woodland Hills, CA
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.
• Presents PQI case review summaries/finding to Medical Director at weekly Case Review Meetings as appropriate.
• Prepares and follows case for subsequent multi-level reviews as needed. This can include review by 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.
• Completes special tasks or projects as assigned.
• Is able to function independently with minimal oversight and direction.
• Responsible for assignments which range from routine to complex in scope.
Unrestricted CA RN license.
General acute care nursing experience or related.