- Full Time/Contract
- Quality Assurance
- Long Beach, CA
Our client is a Managed Care Health Plan that focuses on providing individuals with Medi-Cal, Medicare or Commercial coverage with convenient access to quality, evidence-based medicine, superior value, exceptional service and a network of integrated providers through multiple contracts with various health plans.
LVN; Quality Assurance Nurse
(Managed Care Health Plan)
This position will develop, implement and monitor the goals of the Quality Program. He/she will perform analysis and intervention related to quality of care issues, quality improvement projects and coordination, reports, and ongoing reassessments to sustain improvements in quality measures and service outcomes to meet the demands of contracted health plans and federal and state regulations. This position will oversee the production, analysis, and sets up logistics during HEDIS season.
Essential Functions and Responsibilities of the Job
- Performs qualitative and quantitative analysis to identify significant and problematic clinical issues and concerns, development of improvement plans and measurement to assess impact of actions.
- Participates in accreditation and regulatory audit preparedness and maintains activities including preparing reports, narratives, graphs, charts, etc.as needed for external audits and surveys related to specific topic areas.
- Conducts review and investigation of potential quality of care issues in collaboration with dedicated clinical and non-clinical health plan staff in the Quality and other departments
- Review medical records to determine completeness and accuracy of potential quality of care issues for further action and investigation according to specific process.
- Oversees health promotion and disease management initiatives in within the health plan
- Develops P&Ps, workflows and required documents to meet federal and state regulatory requirements and accreditation, as needed in focus areas.
- Assist Quality Manager and/or Chief Medical Officer with analysis on any gaps in processes and review of potential quality of care issues or other activities related to medical record review that may require remediation and action.
- Follows through primary plans process or investigates when needed patient complaints/grievances received under the direction of the Manger of Quality or the Chief Medical Officer
- Educate primary care practitioners on clinical and preventive health guidelines, primary care operations best practices, documentation standards and coding for outcome reporting
- Distribute reports to providers and members within defined timelines as needed.
- Organizes and maintains filing systems and archived records.
- Occasional travel.
Essential Job Outcomes
- Successfully conduct a qualitative and quantitative analysis to identify significant and problematic clinical issues and concerns.
- Appropriate development of improvement plans and measurement for reassessment.
- Timely submission of grievance/complaints response to the Plans.
- Successful implementation of health promotion and disease management initiatives processes within the health plan.
- NAll delegation audits are completed timely with all materials appropriately prepared.
- Other duties as assigned
QUALIFICATIONS & EDUCATION
- Minimum of 3 years' experience in in a Managed Care/ IPA / MSO Managed Care setting.
- Knowledge of Medicare and Medi-Cal guidelines
- Program development and knowledge of the quality process and QI techniques
- HEDIS, medical record audit or review
- Detail oriented
- Must have excellent communication skills (written and verbal), interpersonal skills, project management and organizational skills.
- Must have excellent PC skills (Word, Excel, Outlook)
- Minimum High School Diploma
- Unrestricted California LVN License
Full Time; Contract to Hire