Under the general supervision of the Clinical Quality Nurse Manager, the Quality Improvement (QI) Nurse Specialist is responsible for the training, certification and recertification of all Alliance Network Management and Delegated Provider Oversight staff conducting site review audits. The QI Nurse Specialist is also responsible for the oversight and monitoring of the qualitative and quantitative content of the medical record process and maintaining compliance with quality of care standards. The QI Nurse Specialist develops provider training and education to meet quality standards.
The Senior QI Nurse Specialist identifies and investigates potential quality care issues. The QI Nurse Specialist prepares cases and presents potential quality care issues to the Medical Director for review and determination.
Principal responsibilities include:
Facility Site Review: · Prepare site review training curriculum for Network Management and Delegated Provider Oversight staff including pre and post testing, and interpreter reliability certification audits.
ESSENTIAL FUNCTIONS OF THE JOB
· Conduct scheduled Facility Site Reviews.
· Consult and review complaints, grievances, and other quality issues.
· Oversee submission of FSR data to the state.
· Train and act as resource for staff performing facility site reviews.
· Frequent offsite travel by automobile is required.
· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Extensive data entry using keyboard and/or mouse.
· Frequent use of telephone headset.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
· Frequent driving of automobile.
EDUCATION OR TRAINING EQUIVALENT TO:
· Registered Nurse with current and active California license.
· Bachelor of Science in Nursing or related field or equivalent experience.
· Have a cleared TB test prior to or within seven days of hire.
· Current CPR and first aid card prior to or within six months of hire is preferred.
· BSN or MSN a plus
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum three years of experience in managed care, hospital, or similar setting.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· DHCS Facility Site Review Master Trainer Certification.
· Direct patient care in hospital, provider’s office, clinic, and other care setting.
· Knowledge of NCQA, Title 22, Title 10, and other regulations governing provider participation in managed care.
· Excellent customer service.
· Experience in utilization management systems.
· Experience with provider facility site review.
· Experience abstracting or screening medical records.
· Familiarity with Microsoft Office suite including databases.
· Excellent verbal and written communication skills.