Quality Assurance/Continuous Improvement Nurse, RN

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Reporting to the Grievance & Appeals (G&A) Quality Supervisor, the G&A Quality Assurance/Continuous Improvement (QA/CI) Nurse, RN is responsible for ensuring the highest quality processes and activities are performed by the G&A clinical staff. Per regulatory requirements, the G&A QA/CI Nurse, RN will assist in the development of quality initiatives and develop & implement the clinical QA Plan. This position performs standardized monitoring and auditing within the G&A department; including all case types: Appeals, Grievances, DMHC cases (Consumer Complaints and Independent Medical Reviews), regulatory and state fair hearing cases. The incumbent develops and utilizes quality auditing tools, summarizes audit findings, and assists leadership in identifying training needs for the G&A clinical staff. Identify Continuous Improvement opportunities through QA and LEAN activities. Ensure compliance with regulatory standards, practices, and guidelines in conjunction with G&A Regulatory Management. Lead and track Continuous improvement projects within the department. The G&A Quality Assurance/Continuous Improvement (QA/CI) RN will support quality assurance efforts related to appropriate Grievance case categorization to include of Quality of Care, identification of Member harm, completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS). Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. • Competitive salary • Telecommute schedule • CalPERS retirement • State of the art fitness center on-site • Medical Insurance with Dental and Vision • Life, short-term, and long-term disability options • Career advancement opportunities and professional development. • Wellness programs that promote a healthy work-life balance • Flexible Spending Account - Health Care/Childcare • CalPERS retirement • 457(b) option with a contribution match • Paid life insurance for employees • Pet care insurance Education & Requirements • Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting • Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting • Two (2) or more years of experience relevant to Grievance & Appeals case review • Associate's degree in nursing from an accredited institution required • Bachelor's degree in nursing from an accredited institution preferred • Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required Key Qualifications • Thorough knowledge of: • Outside agencies and resources such as CCS, CMS, DMHC, or DHCS • Patient rights and ethical decision-making frameworks • Medical necessity and level of care, chronic disease, and complex clinical cases • Diagnostic and procedural understanding in a clinical setting • Regulatory guidelines surrounding Grievances and Appeals per CMS, DHCS, and DMHC and NCQA • Microcomputer applications: spreadsheet, database, and word processing; Excellent interpersonal and communication skills • Time management and priority setting skills • Proven ability to: • Demonstrate a commitment to incorporate LEAN principles into daily work • Work effectively with various internal departments and external Providers and entities • Establish and maintain effective working relationships with others throughout an organization • Assess complex Grievance & Appeal cases and recommend appropriate action • Analyze documentation of incoming cases to determine appropriateness of care and applicable next steps • Effectively escalate issues as identified, following established protocols • Maintain a positive attitude and work in a team setting • Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire • While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell • The employee must occasionally lift or move up to 25 pounds • Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus Start your journey towards a thriving future with IEHP and apply TODAY! Pay Range • $91,249.60 USD Annually - $120,910.40 USD Annually Apply tot his job