Under the direction of the UM Training Manager, the UM Quality Assurance (QA) Nurse is responsible for ensuring the highest quality processes are performed by the t UM Nursing staff. The QA nurse will utilize quality auditing tools, and assist the UM Manager and UM Nurse Trainer in identifying training needs for the prior authorization nursing staff.
- Responsible for ongoing Quality Assurance of UM nursing staff based on audit criteria approved by the Chief of Medical Services.
- Responsible for ongoing Quality Assurance of delegated UM nursing functions for contracted vendors as needed.
- Responsible for assisting in the development, implementation, and evaluation of the overall plan and structure of training programs for the UM Department. Provides tools and training solutions to address any gaps in knowledge, competency and skills.
- Effectively deliver and facilitate adult classroom training and support of UM Programs and processes to ensure superior workforce preparation and meeting accreditation standards and regulatory compliance. Research and evaluate adult learning programs, trends, and practices in order to devise appropriate curriculums.
- Review and report audit findings with UM Management in order to support requirements of accuracy and productivity on a monthly basis.
- Must be familiar with UM regulatory requirements from NCQA, DHCS, DMHC, CMS and any other regulatory agency, utilization of standardized, nationally recognized criteria as approved and accepted by the IEHP UM Subcommittee, UM business rules and medical management system navigation and documentation.
- Responsible for collaborating with departments and supervisors regarding the development, implantation, tracking and feedback components related to quality standards to formulate improved processes for accuracy and assist with the identification of training needs.
- The UM Quality Assurance Nurse will also be responsible for assisting the UM nurses in the day to day functions as needed.
- Work closely with Utilization Management Manager and Director to achieve IEHP Utilization Management goals and regulatory requirements. The UM QA Nurse will also be responsible for collaborating with departments and supervisors regarding the development, implementation, tracking and feedback components related to quality standards.
- Work with UM Nurse Trainer to ensure staff development/training when areas for improvement are identified during QA process.
- Strong coaching, motivational and interpersonal skills are required with an emphasis on service and individual improvement. Use the Kaizen philosophy to mentor Team Members to better their individual skills and meet department and organizational goals. Additionally, this position will participate in LEAN training.
- Any other duties as required, to ensure the success of the organization.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.
Possession of a valid RN license issued by the State of California. Bachelor s degree in nursing or health care related field preferred.
- Three or more years of utilization management experience in a health care delivery setting.
- Experience in an HMO or experience in a Managed Care setting preferred.
- Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements.
- Microcomputer skills, proficiency in Windows applications preferred. ICD-9/10 and CPT coding Professional demeanor, excellent communication and interpersonal skills, strong organizational skills.
- Knowledge of capitated managed care environment helpful. Experience in Excel preferred.
- Exhibits a high attention to detail in documenting UM referral reviews.
- QA scores of 97% or higher for two consecutive years along with score of Exceeds 3 or higher under QA on annual evaluation for two consecutive years.
- Ability to work at a high level of speed while maintaining accuracy.
- Ability to work well with both physician and nursing staff.
Associated topics: ambulatory, bsn, domiciliary, hospice, infusion, nurse, nurse clinical, surgery, surgical, unit
• Post ID: 143006282 inlandempire