Quality Management Nurse Specialist RN II (ALD)

L.A. Care Health Plan • Full-time • Los Angeles, CA, US • 2m ago

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)

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, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Quality Management Nurse Specialist RN II is responsible for overseeing the clinical aspects for quality improvement projects/activities, which may include but are not limited to the clinical review process for potential quality of care and service issues, regulatory compliance with CMS, DMHC, DHCS, and NCQA.

This position is responsible for ensuring program activities are completed in a high quality and timely manner and ensuring compliance with all regulatory guidelines such as Medicaid (Medi-Cal), Medicare, and the Health Exchange, as well as National Committee for Quality Assurance (NCQA) Accreditation.

Duties

Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management.

Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas.

Develops and/or maintains relationships with other external organizations to expand key partnerships.

Creates, maintains and implements training/education and supporting documentation for internal and external clients/customers/members.

Develops and submits regulatory reports at the time and in the manner required by state or federal agencies such as Centers for Medicare and Medicaid Services(CMS).

Conducts/ performs clinical review of assigned potential quality issue cases (PQI), and close cases within regulatory timeframe, and presents appropriate cases to the peer review committee for action and resolution

Perform other duties as assigned.

Duties Continued

Education Required

Associate's Degree in Nursing

Education Preferred

Bachelor's Degree in Nursing

Experience

Required:
At least 5 years of clinical experience as an RN in an acute hospital setting.

Preferred:
Experience with regulatory compliance such as CMS, DMHC, DHCS, and NCQA.

At least 5 years of managed care and/or quality improvement experience as an RN in a managed care/ healthcare setting preferably with Medicare ,Medi-Cal, or other government programs.

Experience in the review of quality of care and service concerns, preferably complaints from member grievance.

Experience in compliance, accreditation, service or quality improvement.

Experience in facilitating workgroups and project management.

Skills

Required:
Must have excellent written and verbal communication and presentation 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.

Must have excellent analytical skills, working knowledge of statistics and reporting.

Must be detail-oriented and effective critical thinking skills.

Proficient in Microsoft Office (Word, Excel).

Strong interpersonal skills and high level of professionalism.

Ability to work independently and within a team environment.

Preferred:
Knowledge in the community standards of practice, including clinical guidelines.

Licenses/Certifications Required

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

Licenses/Certifications Preferred

Certified Professional in Healthcare Quality (CPHQ)

Required Training

Physical Requirements

Light

Additional Information

Preferred:
CPHQ or familiarity with quality improvement methodology such as Lean Six Sigma or Plan-Do-Study-Act.

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

This position is a limited duration position. The term of this position is a minimum one year and maximum of two years from the start date unless terminated earlier by either party. Limited duration positions are full-time positions and are eligible to receive full benefits.

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)

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