Corporate Quality Nurse
Company: Community Health Group
Location: Chula Vista
Posted on: September 13, 2023
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Job Description:
Community Health Group is a locally based non-profit health plan
that ensures access to high quality, culturally sensitive health
care for underserved communities throughout San Diego County. We
treat our 350-member, multi-lingual staff like family, encouraging
an atmosphere of collaborative teamwork, continuous learning,
personal growth, and promotion from within. Recognized as one of
the Top Workplaces in San Diego, CHG offers its employees such
benefits as tuition reimbursement, a meditation room and yoga
classes, a monthly Breakfast With The CEO, and memorable events
throughout the year. We know that by serving our employees well,
they, in turn, will better serve our nearly 300,000+ membership. We
have been recognized consistently for the excellence and
sensitivity of our customer service by members, physicians,
vendors, and a full range of health care providers. We are
accredited by the National Committee for Quality Assurance and
proud of our continuing company-wide Quality Initiatives. We are
currently recruiting for: TITLE: Corporate Quality Nurse Target
Hiring Range: $ 90,412.42- $ 108,494.91 Annually EEO1: Professional
POSITION SUMMARY Serving in a clinical and provider services role,
will be the liaison between Corporate Quality and provider offices.
Will maximize CHG's quality scores by performing chart review in
provider offices to assure proper performance, coding, and
encounter submission of quality measures. Based on audit results
and review of potential quality issues, works with providers to
develop plan for continuously improvement. Will also be responsible
for identifying underperforming provider offices and provide
additional outreach as necessary. RESPONSIBILITIES Responsible for
improving provider performance on HEDIS/Star Rating scores by
regularly performing chart audits and developing improvement plans
specific to issues identified. Understand and educate providers in
proper coding of procedures which qualify for HEDIS/Star Rating
score inclusion. Monitors providers' compliance with regulatory and
company guidelines by performing pre-certification, interim and
periodic medical records' provider compliance surveys and
inspections at primary care and specialty care provider's sites,
using established guidelines; conducting survey exit interviews
with designated site personnel; preparing survey summary reports;
performing follow-up surveys; conducting quality of care reviews.
Works closely with Community Health Group's (CHG's) Grievance and
Appeals Team, Medical Director, and Chief Medical Officer under the
direction of the Director of Corporate Quality to investigate all
member grievance issues and to ensure that care is coordinated.
Searches, investigates, and reviews clinical facts and
circumstances of a complaint, appeal, or sentinel event to identify
and resolve the clinical component of a grievance or quality of
care issue. This review consists of the pertinent medical records
and/or other documentation deemed as necessary as part of the
research and evaluation based on the member's grievance. Presents
cases after the investigation has been completed to either the
Medical Director or Chief Medical Officer to determine the
appropriate clinical determination and leveling of each PQI. Tracks
and trends practitioners and providers regarding PQIs and levels of
severity. Conducts case research and file completion for fair
hearing requests; represents CHG in fair hearings with the Chief
Medical Officer. Participates in or leads performance improvement
projects (PIPs) and Plan-do-Study-Act (PDSA) activities as
assigned. Collects and analyzes data and prepares reports, medical
summaries, corrective action plan letters, education letters, and
other reports and correspondence as applicable. Provides analytical
support to clinical programs; performs clinical assessments and
clinical audits as necessary to support the Corporate Quality
Department responsibilities; Plan, coordinate, deliver and evaluate
clinical training provided to provider sites and internal staff, as
necessary. Complies with and educates providers as necessary on
guidelines established by the Centers for Medicare and Medicaid
(CMS), Department of Health Care Services (DHCS), Department of
Managed Health Care (DMHC), National Committee for Quality
Assurance (NCQA), and other Community Health Group (CHG), where
applicable, as defined in the regulatory guidelines and department
policies. Ensures company compliance with regulatory guidelines by
participating in the preparation process required for regulatory
and accreditation audits; assisting with the implementation of
corrective action plans. And all other duties assigned by the
department director. EDUCATION Current, unrestricted RN license in
California Undergraduate degree or equivalent experience
EXPERIENCE/ SKILLS Two or more years of managed care experience
Basic understanding of medical coding Quality Management, Case
Management or Utilization Management experience preferred Personal
computer experience should include working with Microsoft Word,
Excel, PowerPoint and Outlook at the intermediate level at a
minimum Professional verbal and written communication skills, with
the ability to clearly articulate thoughts and ideas Organizational
skills with the ability to handle multiple tasks and/or projects at
one time Customer service skills with the ability to interact
professionally and effectively with providers, physicians, and
staff from all departments within and outside the Company
Decision-making skills with the ability to investigate and weigh
alternatives and select the course of action that provides the
greatest benefit to the organization Creative thinking skills with
the ability to ask the needed bigger-picture questions that lead to
process and team improvements Problem solving skills with the
ability to look for root causes and implementable, workable
solutions Interpersonal skills with the ability to work in a
fast-paced environment and participate as an independent
contributor with little supervision or as an active team member
depending on the situation and needs Must have a track record of
producing work that is highly accurate, demonstrates attention to
detail, and reflects well on the organization PHYSICAL REQUIREMENTS
Prolonged sitting Occasional traveling, including driving within
County of San Diego Must be able to lift and/or move up to 10
pounds and have close vision May be required to work evenings and
weekends **Must have current authorization to work in the USA**
Community Health Group is an equal opportunity employer that is
committed to diversity and inclusion in the workplace. We prohibit
discrimination and harassment based on any protected characteristic
as outlined by federal, state, or local laws. This policy applies
to all employment practices within our organization, including
hiring, recruiting, promotion, termination, layoff, recall, leave
of absence, compensation, benefits, and trainings. Community Health
Group makes hiring decisions based solely on qualifications, merit,
and business needs at the time. For more information, see Personnel
Policy 3101 Equal Employment Opportunity/Affirmative Action.
Employment Type: Full Time Years Experience: 3 - 5 years
Bonus/Commission: No
Keywords: Community Health Group, Chula Vista , Corporate Quality Nurse, Healthcare , Chula Vista, California
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