Quality Operations Nurse Shift: 10am-7pm
Job ID 2013-21567 # Positions 1
Location US-LA-Baton Rouge
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 1/2/2013
Additional Locations ..
More information about this job:Summary:
Support the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies that impact on plan compliance to regulatory and accreditation standards. Assignments are somewhat broad in nature, often requiring creativity and originality. Review appeals/grievances/quality of care issues received in the Quality Management Department requiring assessment of medical records or clinical information to ensure appropriate processing. Analyze the appeal/grievances/quality of care submission, AMISYS/FACET, CAT database, and clinical resources to ensure that the issue is appropriately processed. Assures documentation of the appeal/grievance/quality of care is appropriate, systems are updated to reflect the issue and that the appeal/grievance/quality of care are routed appropriately. Generate letters to providers/appellants to document appeal/grievance/quality of care documentation requests/outcomes are appropriate.
1. Investigate and research, gather information, send appeal to Medical Director/ like specialty and resolve appeals with letter generation within standard time frames.
2. Assist in implementation and monitoring of quality studies including, but not limited to the development and implementation of preventive health and chronic disease outcomes improvement interventions such as newsletter article, member education and outreach interventions, provider education and outreach interventions, medical record review, focus studies and surveys
3. Participate and contribute to external reviews site visits preparations by the State, accreditation review, Medical Advisory Committee, and Quality Management Committee
4. Conduct internal monitoring and auditing timeline compliance standards. Assist in action plan/interventions as needed with management
5. Research and summarize credentialing files for Committee review, as assigned
6. Process, track and trend, and report medical necessity appeals, grievances, and quality of care issues by line of business for compliance and review
7. Coordinate with departments including Member Services, Provider Relations, Credentialing, Pharmacy and Claims to resolve provider and member issues related to appeals, grievances, and quality of care issues
8. Organize and prioritize clinical job tasks in order of importance and impact on members and providers
9. Investigate and resolves governmental agency and executive level inquiries/issues
10. Prepare medical files for Appeal Committee, Peer Review Committee, and Fair Hearings
11. Perform monthly, quarterly, annual and ad hoc medial record reviews, as assigned
12. Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues
13. Actively participates in quarterly Plan HIPAA audits
14. Maintains member confidentiality and follow HIPAA guidelines
15. Completes special projects or assignments as needed to meet initiatives and/or objectives of the department
16. Review claims/appeals requiring authorization and/or coding review routed to the department for medical necessity and appropriateness based on approved criteria
17. Process and document claims/appeals in compliance with department standard and state regulations
18. Maintains accurate reporting to assure compliance with departmental standards and policies
19. Adhere to company and department policies and procedures related to claims payment, authorization decisions, and overturn/denial decisions related to appeals
20. Other Duties as Assigned
EDUCATION AND EXPERIENCE
- Vocational Nursing diploma or A.A. in Nursing.
Years and Type of Experience Required:
- 3 years of clinical experience.
Certifications or Licensure
- 3-5 years in a managed care environment or related field. Demonstrate leadership, strong communication skills.
- Valid Registered Nurse or Licensed Practical Nurse license.
- Ability to work on multiple projects and tasks on a daily basis; strong presentation/verbal/writing/listening skills; ability and confidence to make decisions based on the scope of the job; ability to travel within the State; Computer literate including word processing and spreadsheet knowledge; excellent verbal and written communication skills; demonstrate strong decision-making skills; ability to work independently and in groups effectively; appreciation of cultural diversity and sensitivity towards target populations
- Must be able to operate a computer.
- Must be able to operate a telephone.
- Must be able to sit for long periods of time.
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