Quality Assurance Nurse
Quantum Health - Ohio

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Quantum Health is a award-winning company that's experiencing explosive growth! As one of the Best Places to Work in Columbus and America, we are looking for some of the best talent in (or around) Columbus. We are currently a Quality Assurance Nurse in our Care Coordination Center. This position combines a variety of Quality Assurance, Case Management and Clinical Reporting activities that share a common denominator: they all require a well rounded, experience-based understanding of all aspects of Care Coordination as practiced at Quantum Health, including administrative customer service (benefits, eligibility, claims) and Care Management (UM, CM and DM).

The Quality Assurance Nurse (QAN) must thoroughly understand how the integration of all of these functions allows and encourages true coordination of care. Based on this understanding, the QAN is part of a team that routinely audits the case activities of all clinical staff, as required by URAC and our own internal Quality Assurance programs. Such audits will cover both clinical standards and care coordination opportunities. Based on audits, the QAN will then participate in providing feedback to all clinical professionals on their performance and providing coaching and ideas on enhancing their performance.

QANs will also participate in the initial training and coaching of new clinical staff as they come on board. To maintain their clinical and care coordination skills, the QAN will also have primary responsibility for Case Managing a certain case load of patients who are flagged for High Cost Case, but who are not otherwise being managed through CM or DM. Finally, the QAN will be a primary liaison with our account executives/managers and performance reporting areas, since they frequently need clinical information, explanation, case summaries and other assistance in the process of conveying our clinical value to client and brokers/consultants. QANs must assure that case summaries are kept up to date for HCC patients, and respond to AEs, AMs and performance analysts when they need assistance documenting or discussing any clinical issues with the market.

The QAN is also part of the Quality Work Team Group. Specific Responsibilitiesfall into four categories, and include but are not limited to: 1. Auditing and Coaching of Clinical Activities Be part of a team of clinical and care coordination professionals who routinely audit the case activities of all clinical staff, including UM (Pre-certification, Concurrent Review and Retrospective Review), Complex Case Management and Chronic Condition Case Management (DM). Audits are regularly conducted to measure performance on both clinical requirements (such as URAC standards) and Care Coordination opportunities identified and addressed.

Specific auditing responsibility will be assigned by the Director of Care Coordination and Quality Assurance Summarize audits for each clinical professional Provide audit feedback to all clinical professionals along with coaching to help all clinical professionals develop Assist in initial training and hands-on coaching of all clinical professionals 2. Hands-on Case Management DocumentationCase Manage patients flagged as High Cost Case who are not otherwise flagged for Case Management or Chronic Condition Management Maintain case summaries for such cases 3. Documentation and Reporting for Critical CasesMaintain case summaries in all patient records for patients flagged as High Cost Cases, and assist in creating case summaries where they are missing for patients flagged as CM or DM Be a primary clinical liaison with Account Executives, Account Managers and Performance Report Analysts to allow Quantum Health to convey to clients how patients are being managed through HCC, Case Management and care coordination Prepare case management summaries for internal and external customers, including but not limited to Clients, Employer Reports, Stop Loss Notification and Stop Loss renewal information Interface with TPA and/or Stop Loss carriers on high cost cases or complex case management patients when requested 4. General ActivitiesAttend Quality Work Team Meetings When requested, review plan documents for recommended benefit language changes or enhancements focusing on clinical issues Other duties as assigned Education, Training, and/or professional experience requirement: Licensed as a Registered Nurse with current license Associates or Bachelors degree in nursing Minimum 3-5 years clinical experience Minimum 3-5 years experience in a health benefits management environment requiring interaction with employer groups, consultants/brokers, carriers, TPAs, Stop Loss carriers Minimum of 5 years experience with self-funded benefit plans including benefit design and plan language Well rounded understanding of all aspects of Care Coordination practiced at Quantum Health, including administrative customer service (benefits, eligibility, claims) and Care Management (UM, CM and DM).

Must understand how the integration of all of these functions allows and encourages true coordination of care Possess excellent verbal and written communication skills including ability to conduct education presentationsAbility to make decisions that are timely and well thought out that achieve results consistent with business goals and organizational culture Ability to work independently and self-directed with limited need for day to day supervision Detail oriented Possess excellent follow through and time management skills Computer literate with the ability to use Microsoft office suite software in a windows based environment Able to function in team environment Strong client relations and customer service skills Nurses interested in working for a company who strives to coordinate care for the patient and family while assisting the physician between visits will find Quantum Health personally and professionally rewarding.And if you join us, we hope that you'll work hard. Have fun. Reap the benefits.On-site fitness facilityPaid maternity and paternity leave for births and adoptionsDomestic partner benefitsFun Room with a pool table, ping pong table and air hockeySerenity Room for relaxation and meditationFrequently catered lunchesFree beverages, snacks and fresh-popped popcorn ALWAYSYes, there's also the "normal" medical/dental/vision insurance, flexible spending accounts, life insurance, 401(k), paid time off and more.If you're ready to take charge of your own future and work for a company where you can really get ahead and what you do everyday matters, we'd love to hear from you.

About this company
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Founded in Columbus in 1999, Quantum Health is an award-winning care management and health improvement company serving the healthcare needs...