Quality Compliance Nurse

Location: Sacramento, CA
Manager, Utilization Management (RN)
 
Joining this team means you'll be surrounded by colleagues who are dedicated to meeting their own high standards, to inspiring their teammates and to making a positive impact on under-insured and uninsured individuals. The group is a fast, agile, customer-focused organization with a commitment to implementing the latest technologies.
 
Our client serves more than 55 million managed care members through their portfolio of high-quality commercial and government sponsored healthcare programs. The broad offering of programs that they provide has helped them to build both capacity and capability to successfully navigate a changing healthcare environment, while continuing to offer better health outcomes at lower costs.
 
Position Purpose:
The Quality Compliance Nurse-CA Only conducts on-site visits, follow-up in-services and participates in corrective action plan completion with individual Primary Care Physicians (PCP) and Participating Provider Groups (PPG) Facility Site and Medical Record Review requirements.
 
Job Description:
  • Demonstrates regular, reliable and predictable attendance.
  • Conducts facility site and medical record reviews with individual PCPs and PPG for Facility Site and Medical Record Review compliance.
  • Coordinates, schedules and completes all site reviews and medical record reviews using Health Care Facility Site and Medical Record Review tool.
  • Completes site reviews and medical record reviews using the Facility Site and Medical Record Review tool.
  • Completes Facility Site and Medical Record Review site tools, containing a confirmation signing by the Primary Care Physician (PCP), and a Corrective Action Plan (AP) report, which includes recommendation for corrections of deficiencies found at the time of the review within agreed upon timeframe.
  • Participates in inter-rater reliability (IRR) audits annually and maintains Reviewer Certification status.
  • Coordinates and conducts both individual and group in-services for PCPs and PPG’s, providing detailed instruction and assistance for implementation of mechanisms to improve compliance with DHS requirements.
  • Addresses and documents Facility Site and Medical Record Review related provider’s issues and stated by individual PCPs and PPGs.
  • Communicates managed care concepts, Health Net’s philosophy, policies to PPGs, individual PCPs, PCP staff, fellow employees and the health care community.
  • Provides professional courtesy, customer friendly services to contracted practitioners and office staff.
 
Qualifications:
Education/Experience:
  • The Quality Compliance Nurse-CA Only conducts on-site visits, follow-up in-services and participates in corrective action plan completion with individual Primary Care Physicians (PCP) and Participating Provider Groups (PPG) Facility Site and Medical Record Review requirements.
  • Education/Experience:
  • Bachelor’s degree in health-related field (Hospital Administration, Health Science, etc.) or strong related experience preferred
  • Communications or business experience in a health-related environment
  • Two to three years’ experience in a managed care environment coordinating programs/seminars for providers
  • 1 – 3 Years Clinical Experience preferred
 
Licenses/Certifications:
  • RN California License with previous regulatory audit experience preferred
  • Facility Site Reviewer Certification
 
Our client offers options that allow you to do more than just plan for retirement. Their programs allow shared success with employees.
  • 401(k) with company match
  • Employee stock purchase plan
  • Training and Learning Opportunities/Tuition Reimbursement/Educational Assistance
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
 
Equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
 
 
 
 
April A. Estes
Senior Recruiter
720-439-2609 Direct
april@proenlist.com 
www.proenlist.com 
www.medenlist.com 
https://www.indeedjobs.com/proenlist?hl=en_US
 
 
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