Quality Management Specialist RN - FT - 545A

Job Description

The Quality Management Specialist - PQI position manages the organization's clinical grievance review process including investigation of all quality reviews 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 grievances/complaints are processed in accordance with regulations, compliance standards and policies and procedures. Processes PQI’s for L.A. Care and monitors PQI’s for plan partners and presents summary of the data at Peer Review Committee.  Meets time frames 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.

Qualifications

EDUCATION

Required: Associates Degree 

Preferred: BSN 

LICENSES/CERTIFICATIONS

Required: Current unrestricted California RN License; valid California driver's license 

EXPERIENCE

Required: With an Associate's Degree in RN:  At least 5 years of quality improvement experience as an RN in a managed care setting preferably with Medicare or other government programs. With a Bachelor's Degree in RN:  At least 3 years of quality improvement experience as an RN in a managed care setting preferably with Medicare or other government programs. Must have excellent written and verbal communication skills. Ability to manage projects independently and assume responsibility for successful completionAbility to develop and maintain strong working relationships with internal and external clients/ customers /members.

Special Instructions

545A