The QI Nurse Specialist-Departmental is responsible for overseeing regulatory reports and audits for the entire Case Management Department to ensure regulatory compliance, implementing and monitoring policy changes to case management reporting and providing quality review of submitted health network data to meet CMS, DHCS and NCQA requirements. Performs analysis and report data related to the Case Management projects and ensures that case management goals and objectives are accomplished within specified time frames. Interacts with other internal CalOptima departments, as well as health networks, and external agencies.
POSITION RESPONSIBILITIES:
- Prepares reports and findings in a clear and concise manner, both written and verbal;
- Collects and analyzes data for regulatory reports, federally and state mandated, audits and forwards to Regulatory Affairs for final review and submission to CMS/DHCS.
- Evaluates reports for data integrity, accuracy and appropriateness and assists in the timely production of reports. Compiles data and prepares reports for management review and approval.
- Participates in annual data validation audit for DHCS.
- Collaborates with revising policies and procedures to align with CMS, DHCS and NCQA standards.
- Assists with the development and oversight of case management programs, work plans and reports.
- Provides support to committees working on quality improvement activities.
- Serves as a liaison and resource between CalOptima and the Health Networks and external agencies.
- Partners with Data Analyst to meet all reporting and project deadlines.
- Other projects and duties as assigned.
Required Skills
- Maintain and ensure confidentiality of patient information.
- Have excellent, professional communication skills both verbal and written with internal and external constituents.
- Work well within a team environment, make recommendations to the team and support the recommendations with clinical rationale.
- Advocate on behalf of the member to ensure quality of care and attainment of appropriate goals.
- Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the population served.
- Access, interpret, manage and modify complex reports and data.
- Work with case management leadership team and Information Services team to develop reports in response to regulatory and business requirements.
- Interpret regulatory requests and assist with audit preparation
- Perform tasks independently and prioritize workload.
- Problem-solve member issues related to health care matters.
- Utilize all available resources when making clinical judgment, independent analysis, and applying evidenced-based clinical guidelines in the decision-making process.
- Utilize and access computer programs (e.g. Microsoft Office; Word, Excel (advance data analysis), PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Required Experience
EXPERIENCE & EDUCATION:
- Associate’s or Bachelor's degree in Nursing, Public Health, Health Policy, Health Care, Public Policy Administration or other related field required.
- Current, unrestricted RN license to practice in the state of California.
- 5 years of clinical experience required.
- Managed care experience strongly preferred.
- CCM certificate desired.
KNOWLEDGE OF:
- Guidelines and regulations relevant to case management and utilization management within the assigned area, discharge planning and utilizing community resources for special services.
- Understand confidentiality and the legal and ethical issues pertaining to case management.
- Medicare and Medicaid/Medi-Cal services, regulations, and populations served.
- A wide variety of medical problems, appropriate treatments and resources for medical treatments and resources in the community.
- Effective charting practices and guidelines.
- Principles and practices of health care, health care systems, and medical administration.
Grade N
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