Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits. Perform community activities related to clinical initiatives such as health fairs and communicate with agencies and providers. Position Responsibilities:
- Perform quality on-site reviews of delegated entities, physician office/clinics, resolve quality issues, generate written summary of findings and follow up as directed by the Medical Director and/or Credentialing and Quality Improvement Committee (QIC).
- Document, investigate and resolve formal and informal complaints, risk management and sentinel events related to quality of care issues.
- Audit medical records, review administrative claims and analyze data and interventions for quality improvement studies and activities
- Function as the primary liaison between community resources/agencies and the company related to clinical initiatives and technical guidance.
- Schedule and chair meetings with delegated entities in accordance with their contract.
- Gather data and compile various utilization and quality improvement reports.
- Develop and implement Corrective Action Plans.
- Recommend changes/enhancements to the Quality Improvement policies and procedures.
- Identify best practices, research new processes and recommend program enhancements.
- Coordinate QIC activities and monthly meetings.
- Oversee the enforcement of contract terms regarding data submission for delegated entities.
- Participate in the development of reporting and data outcome reports.
's degree in nursing preferred. 3-5 years of clinical nursing experience. 2-5 years of experience in quality function in a healthcare setting.
Licenses/Certifications: RN (Registered Nurse), LPN or LVN required. CPHQ (Certified Professional in Healthcare Quality) preferred.