Clinical Quality Review Registered Nurse (RN) Remote for CA residents

Overview: Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Clinical Quality Review Registered Nurse (RN).

Candidate must be authorized to work in USA without requiring sponsorship

* • ********************************************************************** • ** Location: 100% Remote for California Residents

• ** Duration: 9 months contract w/ possibility of extension or conversion to FTE role

Notes:

• 100% remote role for California residents.
• Work Hours: 8:00am - 4:30pm.

Description:

• The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue (PQI) allegations or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in or had the potential for harm to the member and can reputed company to identification of provider opportunities for improvement reputed company to practice patterns that are reputed company the reputed company of accepted standards.
• The Clinical Quality Reviewer, Nurse reputed company will report to the Manager, Clinical Quality Review.
• In this role, you will be responsible for reviewing PQI cases per department protocols through various levels of review and executing follow up actions.
• Analyze quality issues from both internal and external sources.
• Thoroughly investigate, apply critical thinking and clinical judgment to appropriately identify quality of care issues.
• Determine appropriate level of case review needed which may include escalating cases to a medical director, Peer Review Committee or Credentialing Committee to reputed company a final determination.
• Prepare cases for presentation at physician committees as indicated.
• Prepare corrective action plan requests for cases where it is deemed necessary for the provider to institute a change in their present practice.
• Present and discuss corrective action plan responses with medical director and/or Peer Review Committee.
• Manage assigned case load to meet reputed company timeliness metrics.
• May reputed company clinical reputed company.

Qualifications:

• Associate’s or Bachelor’s degree in Nursing.
• California RN license.
• Organizational/computer skills/detail oriented.
• Health plan/IPA experience.
• Remote work experience.

Preferred Qualifications:

• Extensive clinical knowledge and experience, including in hospital setting.
• Previous quality review experience.
• Previous UM or CM experience.
• **********************************************************************

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