Under the general supervision of the Director, Quality Measurement & Program Improvement ,the Senior 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 Senior 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 Senior QI Nurse Specialist develops provider training and education to meet quality standards.
The Senior QI Nurse Specialist identifies and investiges potential quality care issues. The Senior QI Nurse Specialist prepares cases and presents potential quality care issues to the Medical Director for review and determination.
Principal responsibilites include:
Facility Site Review:
· Prepare site review training curriculum for Network Management and Delegated Provider Oversight staff including pre and post testing, and interrater reliability certification audits.
· Conduct certification and recertification audits according to DHCS timelines.
· Conduct, participate, and/or lead facility site review audits, using the DHS/Alliance Site Survey Tool, to assure compliance with local, federal, and state standards. Act as a resource to site review staff.
· Represent the Alliance at DHCS site review workgroup meetings and other state meetings regarding the facility site review process.
· Oversee the preparation and submission of facility site review data to the state.
· Consult with the Medical Director and the Director, Quality Measurement & Program Improvement about urgent quality of care issues and possible reporting requirements.
· Use clinical experience and judgment to assess completeness and appropriateness of provider medical record entries, including history and physical examinations, initial health assessments, progress notes, provider response to lab, and diagnostic study results and consultation reports.
· Use clinical experience and judgment when using a medical record audit tool to measure provider compliance with medical record standards pertaining to legibility, identification, signatures/authentication, mid-level protocols (if applicable), and content; screen for potential and actual quality issues and sentinel events.
· Prepare complete and accurate reports on facility site reviews on a timely basis.
· Identify trends, patterns and opportunities for improvement from provider facility site review processes. Communicate findings with Alliance and provider staff and make recommendations for quality improvement activities and monitoring.
·Follow policies and procedures regarding reporting of quality issues and assist in the preparation of reports and summaries for peer committees.
· Educate providers and office staff about quality improvement processes and corrective action interventions, to facilitate their compliance with Alliance, federal, state, and NCQA standards.
· As per DHCS policy, assign a corrective action plan to a provider when site review scores do not meet minimum DHCS standards.
· Collaborate with provider to ensure provider implements corrective action plan per DHCS policy.
· Complete other duties and special projects as assigned.
Potential Quality Issues (PQI):
· Identify, analyze, and resolve potential quality of care and service issues (PQI).
· Prepare cases for Medical Director to review.
· Assign a corrective action plan to a provider when directed by the Medical Director.
· Collaborate with provider to ensure the provider successfully implements the corrective action plan.
· Work with the Medical Director to ensure the timely processing of PQI.
· Notify the Medical Director immediately about PQI events that are adverse, high risk or may result in a delay of medically necessary care.
· Identify risk or potential risk situations and opportunities for improvement through monitoring and evaluation of the PQI process.
· Prepare PQI reports.
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 resouce 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.
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.
$89,360 - $134,050/annually