Our top healthcare client is seeking a Quality Review RN to investigate and review potential quality of care issues!
Location: This is a fully remote position! Candidates must be located in California.
This job will have the following responsibilities:
- Investigates assigned PQI cases to include obtaining and organizing clinical documents; researching within company databases and outside sources as needed; prepares a written summary of medical and related records relevant to the PQI; determines appropriate review level based on departmental protocols and case findings; records comprehensive rationale for case closure or escalation to next level review.
- Presents PQI case review summaries/finding to Medical Director at weekly Case Review Meetings as appropriate.
- Prepares and follows case for subsequent multi-level reviews as needed. This can include review by a specialty reviewer, Peer Review Committee (PRC) or Credentialing Committee.
Qualifications & Requirements:
- Active and Unrestricted RN License in California
- Bachelor's degree in Nursing or equivalent advanced degree
- 3-5+ years hands on clinical nursing experience across a variety of specialties and settings
- Understanding of Quality management, risk management, peer review, grievance review or equivalent experience required
- Experience with, or strong working knowledge of, regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) and managed care for various lines of business (HMO, PPO, Medicare, Medi-Cal, Cal Medi-Connect)
- Proficiency in use of PC-based software programs including Microsoft Word, Microsoft Outlook and Adobe Acrobat. Strong typing skills required
If interested, please apply directly or reach out to one of my contact methods below ASAP
PHONE/TXT: (484) 753-3515