Under the direction of the Quality Improvement Manager, the QI Nurse I will assist in clinical activities related to monitoring, assessing and improving performance in ambulatory and inpatient health care delivery or health care related services to Program Systems membership. The QI Nurse will assist in the implementation of the PROGRAM QI Program Plan and communicate with contracted providers regarding studies, and will participate in program site reviews, record reviews, chart abstractions and copying records as part of the general QI reporting process which includes data collection, tabulation and report writing.
This position is responsible for assigned Quality Improvement functions for a Knox-Keene Licensed health maintenance organization (HMO).
MAJOR DUTIES AND RESPONSIBILITIES:
- Assist in the implementation of the QI Program Plan and Program Workplan;
- Performs QI activities related to State required Quality requirements
- Serves as knowledge expert for QI activities
- Achieves State certification as a program site reviewer and conducts program site reviews for credentialing and re-credentialing of practitioners and providers as needed. Certification is provided through PROGRAM;
- Participates in record reviews/abstractions/copying;
- Prepares and reports physician specific findings to the Director of QI;
- Assists in problem identification, data analysis, conclusions, recommendations, and action plans;
- Monitors and analyzes outcomes to ensure goals, objectives, outcomes, and regulatory requirements are met;
- Assist in preparation of reports for committees;
- Assists in activities to prioritize QI initiatives;
- Ensures that documentation produced and/or processed complies with State and Federal regulations;
- Assists with training for new employees;
- Assists with internal QI investigations such as records reviews for member complaints involving possible Quality of Care issues
- Assists in problem identification, data analysis, conclusions, recommendations, action plan design, follow-up and tracking.
- Performs all job functions in a safe manner;
- Provides input in support of State and Federal requirements as it pertains to the mandated managed care accountability set measures;
- Maintains the confidentiality of records and reports for both PROGRAM members and contracted providers;
- Performs in-depth medical records reviews as needed and is able to write a professional, clinical summary;
- Knowledge of acute care nursing principles, methods, and commonly used procedures;
- Knowledge of medical terminology, hospital routine; and commonly used medical equipment;
- Knowledge of acute hospital organizations and inter-relationships of various clinical and diagnostic services;
- Performs other job-related duties as required
- Ability to effectively evaluate medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans;
- Ability to assess and judge the clinical performance of physicians and other health professionals;
- Thorough knowledge of health care delivery systems;
- Knowledge of State and Federal managed care regulatory requirements;
- Ability to read, interpret and apply written regulations, guidelines and other materials;
- Strong analytical, assessment and problem-solving skill
- Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of PROGRAM
- Ability to use tact and diplomacy to diffuse emotional situations
- Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards
- Intermediate skills in Word, Excel, PowerPoint, and Outlook, with basic ability to enter data into and navigate through a database
- Ability to commit to and facilitate an atmosphere of collaboration and teamwork
- Knowledge of provider documentation requirements and governmental regulations affecting reimbursement
- Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, PROGRAM business or employee information
CORE COMPENTENCIES / KNOWLEDGE & SKILLS:
- Self-directed, with proven ability to work independently with minimum supervision
- Uses appropriate judgment and asks questions and seeks assistance appropriately
- Demonstrated ability to multi-task and complete assignments on a timely basis
- Strong attention to detail; works accurately and meets expected deadlines and target dates
- Ability to communicate effectively with contracting physicians, other ancillary providers and internal departments
- Compliant with PROGRAM policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.
- Associate Degree in Nursing from an accredited institution or equivalent required
- Bachelor of science (BSN) Preferred.
- Three (3) years of RN experience in a direct patient care setting preferred
- One (1) year experience in Utilization Management or QI in a healthcare delivery or managed care setting required.
- Possession of a valid California Registered Nursing License and in good standing
- Managed health care and Knox-Keene licensure requirements
- Applicable State and NCQA standards and regulations pertaining to quality improvement management programs
- HEDIS data collection and analysis
- Quality improvement study design methods and appropriate quality improvement tools and applications is preferred
- Microsoft Office programs including Word, Excel, and PowerPoint.
- Communicate effectively with contracting physicians, other ancillary providers and internal departments.
- Address interpersonal issues that arise using conflict resolution skills.Problem-solve issues identified with projects, assignments, or processes.
- Write reports and clinical summaries in a clear, succinct, and professional manner.
- Maintain proper documentation and confidentiality.
- Possess good organizational skills and able to work independently.
**Depending on the duties assigned to this position, certification by the CA Department of Health Care Services (DHCS) as a site reviewer may be required upon completion of required training.
Other: Possession of valid driver’s license and proof of State required auto liability insurance. Up to 50% driving required.