Provider Quality Review Nurse, RN

This is a short-term assignment.  

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!

At Inland Empire Health Plan (IEHP), we believe the highest quality of care should be delivered to all in the Inland Empire.  We are thinking beyond the way Quality is viewed today – we believe it should be holistic and transformative.  IEHP’s provider incentive programs serve an important role in achieving IEHP’s quality goals.

Reporting to the Manager of Provider Quality Oversight, the Provider Quality Review Nurse, RN is responsible for:

• Receive and research all PQI and QR cases as assigned, provide a summary and recommendations to the Medical Director of case assignments
• Effectuate all action items as determined by the Medical Director to resolution of case assignments
• Reviewing escalated issues
• Discussing and reviewing cases with Medical Directors referred to the Quality Management (QM) department
• Investigation of cases includes, but not limited to, the documentation of case summaries, follow up actions, outreach efforts, and communications in the QM database

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.

1. Investigate and complete case summaries and make recommendations for any Potential Quality of Care Incidents (PQI) referred to the QM department.
2. Maintain direct communication with IEHP departments, external facilities including hospitals, Skilled Nursing Facilities, and/or Providers to ensure all PQI issues are thoroughly investigated, and care is coordinated in a timely manner, as needed.
3. Review requested medical records to ensure complete case documentation is received from all practitioners, providers, and entities/agencies to ensure thorough investigation of the issue.
4. Review case findings and recommendations with Medical Director. Issue Corrective Action Plans (CAP), review CAP responses, draft Opportunity for Improvement letters, and coordinate other interventions as needed to ensure all issues were addressed and future occurrences of the same issue are mitigated.
5. Complete data entry into database systems, maintain updated documentation and other tracking mechanisms for all cases.
6. Review and execute ad hoc requests, quality reviews, and/or focused audits, as needed.
7. Escalate issues of non-compliance to the Quality Systems Management team.
8. Maintain working knowledge of regulatory requirements as they relate to QM operations and protocols.
9. Complete other tasks and assignments based on department and business needs.
10. Demonstrate a commitment to incorporate LEAN principles into daily work.

Education & Requirements 

• Three (3) or more years of any individual or combined healthcare experience in quality assurance, quality management, quality improvement, utilization management, discharge planning, and/or case management
• Three (3) or more years of work experience in a managed care, hospital, provider practice, or other comparable healthcare experience
• Experience preferably in a quality/performance improvement setting
• Bachelor's degree in Nursing from an accredited institution required
  • In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
  • This experience is in addition to the minimum years listed in the Experience Requirements above
• Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Clinical certification in area specialty) preferred
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required

Key Qualifications

• Must have a valid California Driver's License
• Excellent understanding of performance improvement, quality assurance, and utilization management
• Knowledgeable in clinical analysis of health records, assessing or evaluating quality, and identifying problems or issues with care delivery
• Microcomputer applications: spreadsheet, database, and word processing
• Excellent written and verbal communication skills
• Excellent coordination skills
• Ability to communicate findings and form recommendations based on clinical case reviews
• Ability to demonstrate critical thinking, strong problem-solving capability. Strong attention to detail
• Ability to prioritize work to ensure adherence to project deadlines. Ability to effectively escalate issues as identified, following established protocols
• Positive attitude and ability to work in a team setting
• Self-direction and ability to work with minimal supervision
• Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire
• Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval

Start your journey towards a thriving future with IEHP and apply TODAY!

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)