Quality Improvement Nurse (RN) – Managed Care
Your Job Summary:
The Quality Improvement Nurse performs all aspects of the Quality Improvement Program, including activities related to Utilization Review Denials, Appeals, and Grievances. The Quality Improvement Nurse will analyze medical charts, trend lines and applicable transparency websites in order to determine whether there are adverse trends and/or sites of excellence. Will also conduct peer review cases to ensure compliance with standards. Ensure that the health plan and its contracted network provide members with appropriate and timely and quality of care and services.
EXCELLENT BENEFITS AND HIGHLY COMPETITIVE SALARY OFFERED!
This established, nationally-recognized organization is a Fortune 500 company that is committed to the health and happiness of all their staff. They offer a comprehensive benefits package to all full-time, permanent employees including low cost health insurance plan, dental, vision, and life insurance. To assist employees in living a healthier life, they offer either on-site fitness center or discounts to local fitness centers and a comprehensive wellness programs. They also offer free or reimbursed parking, tuition assistance, matching 401(k), employee stock purchase plan, generous PTO plus paid holidays, and much more!
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
Certified Professional in Healthcare Quality (CPHQ) or similar certification is preferred.
Bachelor’s of Science in Nursing (BSN) or related healthcare field is a plus.
Roughly 2-5 years acute care clinical nursing experience is required.
Around 2-4 years of recent experience in Quality Improvement or Quality Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Facilitates continuous improvement in the health plan delegated networks by providing individualized case review and processing. Performs clinical review related to Grievances, Appeals, Quality Referrals and Occurrences by identifying the issues of the case, ordering and collecting needed documents or records, reviewing the case documents, completing a case summary, and either leveling or reviewing the case with the Medical Director as appropriate. Maintains strict compliance with federal, state and NCQA requirements and guidelines. Participates in and coordinates Quality Improvement committee activities by assisting with development of the agenda, providing the assigned meeting documents, presenting reports and reviewing/ finalizing the meeting minutes. Provides complete and accurate documentation of work performed by keying data into specified databases or forms as instructed and reporting any required metrics. Participates in the Quality Improvement process by identifying problems, examining solutions options, implementing action plans and by coordinating, facilitating and/or participating in inter and intradepartmental quality initiatives and work groups.