Position Summary The RN, Quality Improvement (QI) will support the Quality Improvement and Health Services Programs, assisting the health plan to successfully achieve organizational objectives for clinical quality and patient safety. This position will be responsible for core clinical and regulatory compliance functions within the QI and Health Services arena, including Facility Site Review (FSR) Medical Record Review (MRR), Potential Quality Issue (PQI) investigation and reporting, and liaison with the team in designing and implementing clinical quality improvement strategies and interventions to support quality metrics and regulatory requirements. The RN, Quality Improvement I will work closely with the Health Services leadership team and the Chief Medical Officer to assess the Program\'s outcomes, identify areas of needed improvement, and institute actions to promote the delivery of high-quality care. This employee must be able to interpret the requirements of the Plan\'s regulatory bodies, and state and federal regulations, NCQA accreditation standards, and institute processes/programs to ensure compliance.
Amount of Travel Required: 30-50%
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
ESSENTIAL FUNCTIONS
Job Function & Responsibilities
Work closely with other departments of the Health Plan, Health Services and QIHET team, and Chief Medical Officer to achieve the goals of the Quality Improvement and Health Equity Transformation (QIHET) Program by identifying issues and implementing corrective actions to ensure compliance with DHCS regulatory requirements and optimize GCHP quality performance.
Lead the timely investigation, processing, and reporting of identified potential quality issues (PQI following the Plan\'s procedures and timelines).
Track and trend PQI outcomes for the purpose of reporting and prioritization of improvement actions/interventions.
Annually review and edit relevant policies and procedures per APL updates, regulatory requirements, NCQA standards and/or required process changes.
Conduct facility site reviews (FSR), Medical Record Reviews (MRR), and/or Physical Accessibility Review Surveys (PARS) according to DHCS site survey requirements and maintain the FSR database for ongoing tracking of contracted sites and reporting purposes.
Ensure timely follow up on all FSR/MRR activities, including provider communication and corrective action plan documentation.
Lead and/or participate in quality improvement activities and audits, including but not limited to, focused medical record review (MRR), monitoring of Initial Health Appointment (IHA), blood lead screening in children, and other performance improvement projects.
Participate and/or provide clinical support to regulatory compliance activities, including but not limited to, DHCS Medical Audits, HEDIS compliance audits, and internal/external audits.
Support, as needed, the annual HEDIS project, including medical record abstraction and over-reads to determine compliance with HEDIS measures and optimize performance outcomes.
Utilize clinical expertise to create and/or revise policies and procedures per new APL requirements, regulatory requirements, and/or NCQA standards, establish QIHET work plan metrics and key performance indicators, implement provider training programs, and develop member and provider newsletter and website content.
Lead, facilitate and/or participate in relevant committees and work groups; prepare reports, data, or other materials for committee presentation.
Complete project-related communications, including job aides, member/physician communications, website content, work plans/action plans, graphical analyses, and agendas/minutes, as applicable.
Research best practices, and industry standards to help promulgate quality outcomes for the Plan.
Demonstrate strong critical thinking, collaboration, and work ethic, with the ability to foster teamwork and work effectively with providers and multi-disciplinary teams, and adapt quickly to changing priorities
Perform all other duties as assigned.
MINIMUM QUALIFICATIONS
Education & Experience:
Required Education and Experience
Current CA Registered Nursing License - Unencumbered
Associate or bachelor\'s degree (two or four-year college or technical school) Required, Field of Study: Nursing
1-2 years of clinical experience in Quality Improvement, Risk Management, Compliance, and/or Accreditation demonstrating increasing responsibility in clinical quality improvement.
KNOWLEDGE, SKILLS & ABILITIES
Analytical and problem-solving acumen.
Critical thinking skills
Excellent verbal and written communication skills and ability to interact in a positive manner within the medical/clinic community.
Team player who builds effective working relationships within and across teams.
Ability to work independently.
Strong organizational skills
Ability to analyze, interpret, apply, and communicate policies, procedures and regulations.
Understanding and ability to perform data analysis, basic statistical skills including intermediate knowledge of Excel.
Proven experience with performance improvement methodologies required.
PREFERRED QUALIFICATIONS
Public Health and/or ambulatory care/clinic setting background
Medicaid Health Plan experience
Certified Facility Site Reviewer or FSR experience
Knowledge of quality improvement processes and risk mitigation strategies in a managed care environment.
Knowledge of DHCS requirements, NCQA Accreditation standards, and HEDIS.
Technology & Software Skills:
Highly competent in the MS Office products including proficiency in Word, Excel, PowerPoint, and databases.
Working knowledge with electronic health record systems including Cerner, NextGen, and Meditech.
Certifications & Licenses: A valid and current Driver\'s License, Auto Insurance, and Current CA Registered Nurse licensure(s)
Competency Statements
Business Acumen - Ability to grasp and understand business concepts and issues.
Decision Making - Ability to make critical decisions while following company procedures.
Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
Interpersonal - Ability to get along well with a variety of personalities and individuals.
Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
Consensus Building - Ability to bring about group solidarity to achieve a goal.
Relationship Building - Ability to effectively build relationships with customers and co-workers.
Presentation Skills - Ability to effectively present information publicly.
Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
Judgment - The ability to formulate a sound decision using the available information.
Communication, Oral - Ability to communicate effectively with others using the spoken word.
Communication, Written - Ability to communicate in writing clearly and concisely.
Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.