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Provider Quality Nurse Specialist RN II (Temporary)

Company: L.A. Care Health Plan
Location: Los Angeles
Posted on: May 24, 2020

Job Description:

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in six health plans, we make sure our members get the right care at the right place at the right time.


Job Summary

The Provider Quality Nurse Specialist RN II - Provider Quality Review (PQR) position manages the organization's clinical review process for potential quality of care concerns and quality of service and access issues, including collection of appropriate data. Closes cases by preparing and submitting the case(s) to the appropriate physician reviewer and committees for case closure. Ensures clinical reviews are processed in accordance with regulations, compliance standards and policies and procedures. Processes potential for L.A. Care and monitors PQI's for plan partners/delegates and presents summary of the data at Peer Review Committee. Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues. Ensures integrity of departmental database by thorough, timely and accurate entry of cases. Performs investigations of unusual occurrences/events from sources (providers, staff, hotline, etc.) and assesses criticality of events.



Duties

Handles inquiries & resolution of clinical operational issues. Make decisions using clinical judgment.

Develops and maintains positive working relationships with internal and external clients/ customers/members.

Participates in special projects, working with other departments and attending scheduled meetings. Meets or exceeds deadlines.

Creates, maintains and implements training / education and supporting documentation for internal and external clients / customers / members. Reports and tracks data in support of clinical operational goals and initiatives of the work unit /L.A. Care annual QI work plan.

Participates in the implementation of QI initiatives. Leads meetings and collaborates with internal organizations and external clients to resolve issues and improve processes.

Perform other duties as assigned.



Education Required

Associate's Degree in Nursing



Education Preferred

Bachelor's Degree in Nursing



Experience

Required:At least 5-7 years of quality improvement experience as an RN in a managed care setting preferably with Medicare or other government programs.



Skills

Required:Must have excellent written and verbal communication skills.

Ability to manage projects independently and assume responsibility for successful completion.

Ability to develop and maintain strong working relationships with internal and external clients/ customers /members.



Licenses/Certifications Required

Registered Nurse (RN) - Active, current and unrestricted California License



Licenses/Certifications Preferred



Required Training



Additional Information





L.A. Care offers a wide range of benefits including


  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

Keywords: L.A. Care Health Plan, Los Angeles , Provider Quality Nurse Specialist RN II (Temporary), Healthcare , Los Angeles, California

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