Position Summary/Position

Reporting to the Manager of Provider Quality Oversight, the Provider Quality Review Nurse, RN is responsible for:

- Receive and research all PQI and QR cases as assigned, provide a summary and recommendations to the Medical Director of case assignments.
- Effectuate all action items as determined by the Medical Director to resolution of case assignments.
- Reviewing escalated issues
- Discussing, and reviewing cases with Medical Directors referred to the Quality Management (QM) department.
- Investigation of cases includes, but not limited to, the documentation of case summaries, follow up actions, outreach efforts, and communications in the QM database.

Major Functions (Duties and Responsibilities)

1. Investigate and complete case summaries and make recommendations for any Potential Quality of Care Incidents (PQI) referred to the QM department.
2. Maintain direct communication with departments, external facilities including hospitals, Skilled Nursing Facilities, and/or Providers to ensure all PQI issues are thoroughly investigated, and care is coordinated in a timely manner, as needed.
3. Review requested medical records to ensure complete case documentation is received from all practitioners, providers, and entities/agencies to ensure thorough investigation of the issue.
4. Review case findings and recommendations with Medical Director. Issue Corrective Action Plans (CAP), review CAP responses, draft Opportunity for Improvement letters, and coordinate other interventions as needed to ensure all issues were addressed and future occurrences of the same issue are mitigated.
5. Complete data entry into database systems, maintain updated documentation and other tracking mechanisms for all cases.
6. Review and execute ad hoc requests, quality reviews, and/or focused audits, as needed.
7. Escalate issues of non-compliance to the Quality Systems Management team.
8. Maintain working knowledge of regulatory requirements as they relate to QM operations and protocols.
9. Complete other tasks and assignments based on department and business needs.
10. Demonstrate a commitment to incorporate LEAN principles into daily work.

Experience Qualifications

Three (3) or more years of any individual or combined healthcare experience in quality assurance, quality management, quality improvement, utilization management, discharge planning, and/or case management. Three (3) or more years of work experience in a managed care, hospital, provider practice, or other comparable healthcare experience.

Preferred Experience

Experience preferably in a quality/performance improvement setting.

Education Qualifications

Bachelor's degree in Nursing from an accredited institution required.

In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above.

Preferred Education
Professional Certification

Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Clinical certification in area specialty) preferred.

Professional Licenses

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Drivers License Required
Yes, must have a valid California Driver's License.

Knowledge Requirement

Excellent understanding of performance improvement, quality assurance, and utilization management. Knowledgeable in clinical analysis of health records, assessing or evaluating quality, and identifying problems or issues with care delivery.

Skills Requirement

Microcomputer applications: spreadsheet, database, and word processing. Excellent written and verbal communication skills. Excellent coordination skills. Ability to communicate findings and form recommendations based on clinical case reviews.

Abilities Requirement

Ability to demonstrate critical thinking, strong problem-solving capability. Strong attention to detail. Ability to prioritize work to ensure adherence to project deadlines. Ability to effectively escalate issues as identified, following established protocols. Positive attitude and ability to work in a team setting. Self-direction and ability to work with minimal supervision.