Overview
The RN, Quality Improvement (QI) III will support the Quality Improvement and Health Services Programs, assisting the health plan to successfully achieve organizational objectives for clinical quality and patient safety. This position will be responsible for leading core clinical and regulatory compliance functions within the QI and Health Services arena, including Facility Site Review (FSR), Medical Record Review (MRR), Potential Quality Issue (PQI) investigation and reporting, and liaison with the team in designing and implementing clinical quality improvement strategies and interventions to support quality metrics and regulatory requirements. The RN, Quality Improvement III will work closely with the Health Services leadership team and the Chief Medical Officer to assess the Quality Improvement Program's outcomes, identify areas of needed improvement, and institute actions to promote the delivery of high-quality care. This employee must be able to interpret the requirements of the Plan's regulatory bodies, and state and federal regulations, NCQA accreditation standards, and institute processes/ programs to ensure compliance
Job Details:
- Work closely with other departments of the Health Plan, Health Services and Ql teams, and Chief Medical Officer to achieve the goals of the Quality Improvement and Health Equity Transformation (QIHET) Program by identifying issues and implementing corrective actions to ensure compliance with DHCS regulatory requirements and optimize GCHP quality performance.
- Lead the timely investigation, processing, and reporting of identified potential quality issues (PQIs) following the Plan's procedures and timelines and regulatory requirements.
- Track and trend PQI outcomes for the purpose of reporting and prioritization of improvement actions/interventions.
- Annually review and edit relevant policies and procedures per APL updates, regulatory requirements, NCQA standards and/or required process changes.
- Conduct facility site reviews (FSR), Medical Record Reviews (MRR), and/or Physical Accessibility Review Surveys (PARS) according to DHCS site survey requirements and maintain the FSR database for ongoing tracking of contracted sites and reporting purposes. Directs and facilitates quality improvement activities and audits, including but not limited to, focused medical record review, monitoring of Initial Health Appointment (IHA), blood lead screening in children, and other performance improvement projects.
- Responsible for providing clinical support to regulatory compliance activities, including but not limited to, DHCS Medical Audits, HEDIS®compliance audits, and internal/external audits.
- Support, as needed, the annual HEDIS project, including medical record abstraction and over-reads to determine compliance with HEDIS measures and optimize performance outcomes.
- Utilize clinical expertise to create and/or revise policies and procedures per new APL requirements, regulatory requirements, and/or NCQA standards, establish and lead QIHET work plan metrics and key performance indicators, implement and lead provider training programs, and develop member and provider newsletter and website content.
Job Requirements:
- Current CA Registered Nursing License - Unencumbered
- CSR is a MUST
- Bachelor's Degree (four-year college or technical school) Required, Field of Study: Nursing 5 plus years of clinical experience in Quality Improvement, Risk Management, Compliance, and/or Accreditation demonstrating increasing responsibility in clinical quality improvement.
- 5 plus years’ experience in Health Plan, Public Health and/or ambulatory care/clinic setting background
To Apply download our app 360X JOBS, visit our website www.360xstaffing.com and click "Join our Team."
Pay: $60.00 - $65.00 per hour
Work Location: In person
