Corporate Quality Nurse


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 300-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:

Corporate Quality Nurse

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, will work with providers to develop plan for continuously improvement.  Will also be responsible for identifying underperforming provider offices and provide additional outreach as necessary.

 

RESPONSIBILITIES

  • Educate providers about Community Health Group quality improvement program standards for 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) quality initiatives.

  • Responsible for improving provider performance on HEDIS/Star Rating scores by regularly performing chart audits and developing improvement plans specific to issues identified.

  • Educate providers about Community Health Group’s incentive programs for providers and members.

  • 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 with provider to resolve clinical problems and resolution of issues concerning members through the member grievance and fair hearing process

  • Participate in annual HEDIS/Star Rating audit through communication with offices, coordinating and performing chart reviews, and post audit follow up with provider offices

  • 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.

  • Collaborates with Chief Medical Office to provide appropriate clinical response to Quality of Care referrals and DHCS Fair Hearing requests.

  • Works collaboratively with the Plan Compliance to meet all regulatory criteria and timeframes for complaint responses.

  • Assure assigned providers receive timely, actionable information including regular lists of members with unmet gaps in care for HEDIS/Star Rating measures.

  • Complies with all 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 weekend