Job Description

Overview What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Reporting to the Grievance & Appeals (G&A) Quality Supervisor, the G&A Quality Assurance/Continuous Improvement (QA/CI) Nurse, RN is responsible for ensuring the highest quality processes and activities are performed by the G&A clinical staff. Per regulatory requirements, the G&A QA/CI Nurse, RN will assist in the development of quality initiatives and develop & implement the clinical QA Plan. This position performs standardized monitoring and auditing within the G&A department; including all case types: Appeals, Grievances, DMHC cases (Consumer Complaints and Independent Medical Reviews), regulatory and state fair hearing cases. The incumbent develops and utilizes quality auditing tools, summarizes audit findings, and assists leadership in identifying training needs for the G&A clinical staff. Identify Continuous Improvement opportunities through QA and LEAN activities. Ensure compliance with regulatory standards, practices, and guidelines in conjunction with G&A Regulatory Management. Lead and track Continuous improvement projects within the department. The G&A Quality Assurance/Continuous Improvement (QA/CI) RN will support quality assurance efforts related to appropriate Grievance case categorization to include of Quality of Care, identification of Member harm, completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS). Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary CalPERS retirement State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development. Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Serve as a subject matter expert for Grievance and Appeals (G&A) and is a resource for clinical and non-clinical Team Members in expediting the resolution of outstanding issues. In collaboration with the centralized trainers, effectively reinforce classroom training to support G&A Departmental processes to ensure superior workforce preparation and meeting accreditation standards and regulatory compliance. Create reports to evaluate additional training needed. Work closely with the multiple stakeholders (including, but not limited to, Grievance Nurse Leadership, Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/DHS/CMS) to ensure all member grievance issues are investigated in addition to ensuring care is coordinated appropriately and in adherence to Grievance and Appeals Policies and Procedures. Complete Quality Assurance (QA) activities focused on triage of new cases to identify medical urgency and the potential need for Organizational Determination and notify the Immediate Needs team to ensure timely resolution. Complete QA activities for G&A case categorization and classification to ensure it is accurate. Assist in the resolution of member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the member's care. Comply with mandated reporting obligations and serve as the first line to report allegations of physical and sexual abuse to the appropriate authorities. Lead and track clinical focused Continuous improvement projects within the department. Conduct ongoing quality auditing of G&A clinical staff and operations of G&A activities, to include appropriate and consistent application of G&A categorization specific to Quality of Care, timely identification of Member Harm and appropriate mitigation, clinically appropriate investigations in all G&A case types (grievance, appeals, regulatory). Ensure policies, procedures, standard work, and job aides are accurate and updated as necessary. Identify Department training needs based on quality audit trends of systems, processes, and personnel. Based on performance metrics and collaboration with G&A leadership, assist in identifying Team Member deficiencies and formulate quality improvement work plans with focus on Quality of Care and Member Harm Collaborate with centralized training team to facilitate individual training plans to ensure the completion of departmental cross training and continuous new/refresher trainings are coordinated efficiently and effectively to address business needs specific to the G&A clinical staff. Provides tools and immediate on the job training to address any gaps in G&A team members knowledge, competency, and skills. Assist with Health Plan Level case quality assurance auditing prior to case submission to regulatory entities (e.g., DMHC, DHCS, CMS, NCQA, etc.) specific to Quality of Care, Member Harm and clinical investigations. Responsible for QA on topics such as regulatory requirements from NCQA, DHCS, DMHC, CMS and any other regulatory agency pertaining to clinical investigations and categorization. Maintain 100% oversight of all Quality-of-Care cases and provide training on gaps/barriers identified. Also provide QA support to both the Appeals unit and G&A Regulatory unit. Assist with regulatory audit file preparation and quality assurance with focus on identification of clinical gaps in medical investigations, categorization, recommendations and the identification of Member Harm. Identify Continuous Improvement opportunities through QA and LEAN activities. Lead and track Continuous improvement projects within the department specific to clinical investigations. Perform any other duties as required to ensure Health Plan operations and department business needs are successful. Qualifications Education & Requirements Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting Two (2) or more years of experience relevant to Grievance & Appeals case review Associate's degree in nursing from an accredited institution required Bachelor's degree in nursing from an accredited institution preferred Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required Key Qualifications Thorough knowledge of: Outside agencies and resources such as CCS, CMS, DMHC, or DHCS Patient rights and ethical decision-making frameworks Medical necessity and level of care, chronic disease, and complex clinical cases Diagnostic and procedural understanding in a clinical setting Regulatory guidelines surrounding Grievances and Appeals per CMS, DHCS, and DMHC and NCQA Microcomputer applications: spreadsheet, database, and word processing; Excellent interpersonal and communication skills Time management and priority setting skills Proven ability to: Demonstrate a commitment to incorporate LEAN principles into daily work Work effectively with various internal departments and external Providers and entities Establish and maintain effective working relationships with others throughout an organization Assess complex Grievance & Appeal cases and recommend appropriate action Analyze documentation of incoming cases to determine appropriateness of care and applicable next steps Effectively escalate issues as identified, following established protocols Maintain a positive attitude and work in a team setting Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell The employee must occasionally lift or move up to 25 pounds Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range USD $91,249.60 - USD $120,910.40 /Yr. Inland Empire Health Plan

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