Nurse RN

Day to Day Responsibilities

The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue (PQI) allegations or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in or had the potential for harm to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards.

The Clinical Quality Reviewer will report to the Manager, Clinical Quality Review. In this role, you will be responsible for reviewing PQI cases per department protocols through various levels of review and executing follow up actions.

• Analyze quality issues from both internal and external sources
• Thoroughly investigate, apply critical thinking and clinical judgment to appropriately identify quality of care issues
• Determine appropriate level of case review needed which may include escalating cases to a medical director, Peer Review Committee or Credentialing Committee to render a final determination
• Prepare cases for presentation at physician committees as indicated
• Prepare corrective action plan requests for cases where it is deemed necessary for the provider to institute a change in their present practice
• Present and discuss corrective action plan responses with medical director and/or Peer Review Committee
• Manage assigned case load to meet all timeliness metrics
• May perform clinical oversight

• Organizational/computer skills/detail oriented
• Health plan/IPA experience in a remote environment
• Extensive clinical knowledge and experience, including in hospital setting - including behavioral health for occasional coverage needs

• Previous quality review experience
• Previous UM or CM experience
• Excellent communication/case presentation skills

• Lack of remote work experience; spelling/formatting/grammatical errors

• Associate's or Bachelor's degree in Nursing

• None

• Microsoft Office, including ability to manage Excel spreadsheets;
  Adobe Acrobat

• Current unencumbered CA RN license