Full Benefits: Medical, Dental, Vision, Retirement, ETC.
*Bonus*
Internal Number: 1712
Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.
**TELECOMMUTE Available**
PRIMARY PURPOSE
Under the direction of the Quality Improvement Manager, the QI Nurse I will assist in clinical activities related to monitoring, assessing and improving performance in ambulatory and inpatient health care delivery or health care related services to Kern Health Systems (KHS) membership. The QI Nurse will assist in the implementation of the KHS QI Program Plan by doing one or more of the following activities:
• Communicate with contracted providers regarding studies and audit findings,
• Deliver provider or member education in support of quality health care,
• Conduct provider site reviews, medical record reviews and audits, and HEDIS or HEDIS-like chart reviews,
• Perform clinical investigation of potential quality of care issues and grievances and write an effective clinical summary of the investigation for referral to a medical director,
• Develop and ensure completion of provider corrective action plans related to quality of care issues or regulatory or accreditation non-compliance,
• Develop and complete performance improvement projects aimed at improving member compliance with specific preventive health measures.
DISTINGUISHING CHARACTERISTICS
This position is responsible for assigned Quality Improvement functions for a Knox-Keene
Licensed health maintenance organization (HMO).
MAJOR DUTIES AND RESPONSIBILITIES
• Assist in the implementation of the QI Program Plan and Program Workplan.
• Performs QI activities related to State required Quality requirements
• Serves as knowledge expert for KHS QI activities
• May be required to achieve State certification through the California Department of Health Services as a facility site reviewer and conduct facility site reviews for credentialing and re-credentialing of practitioners and providers. Certification is provided through KHS.
• Performs and documents HEDIS or HEDIS-like medical record reviews to assess compliance with specific measures.
• Performs clinical assessment of member grievances to determine if a potential quality of care issue exists and writes a clinical summary of the screening assessment for presentation to the medical director.
• Performs clinical investigation and assessment of potential quality of care issue referrals to determine if a quality-of-care issue exists and writes a clinical summary of the clinical investigation for presentation to the medical director,
• Works with the medical director to support timely and complete follow up of grievance reviews, potential quality of care issues, provider responses for additional information requests and corrective action plans.
• Participates in problem identification, data analysis, conclusions, recommendations, and action plans.
• Monitors and analyzes outcomes to ensure goals, objectives, outcomes, and regulatory requirements are met.
• Assists in preparation of reports for committees.
• Assists in activities to prioritize QI initiatives.
• Ensures that documentation produced and/or processed complies with State and Federal regulations.
• Assists with training and orientation for new employees.
• Performs all job functions in a safe manner.
• Provides input in support of State and Federal requirements as it pertains to the mandated managed care accountability set (MCAS) measures.
• Maintains the confidentiality of records and reports for both KHS members and contracted providers.
• Performs in-depth medical records reviews as needed and is able to write a professional, clinical summary.
• Knowledge of acute care nursing principles, methods, and commonly used procedures.
• Knowledge of medical terminology, hospital routine; and commonly used medical equipment.
• Knowledge of acute hospital organizations and inter-relationships of various clinical and diagnostic services.
• Ability to effectively evaluate medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans.
• Ability to assess and judge the clinical performance of physicians and other health professionals.
• Thorough knowledge of health care delivery systems.
• Knowledge of State and Federal managed care regulatory requirements.
• Ability to read, interpret and apply written regulations, guidelines and other materials.
• Strong analytical, assessment and problem-solving skills.
• Strong people skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of KHS.
• Ability to use tact and diplomacy to diffuse emotional situations.
• Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards.
• Intermediate skills in Word, Excel, PowerPoint, and Outlook, with basic ability to enter data into and navigate through a database.
• Ability to commit to and facilitate an atmosphere of collaboration and teamwork.
• Knowledge of provider documentation requirements and governmental regulations affecting reimbursement.
• Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information.
• Self-directed, with proven ability to work independently with minimum supervision.
• Uses appropriate judgment and asks questions and seeks assistance appropriately.
• Demonstrated ability to multi-task and complete assignments on a timely basis.
• Strong attention to detail; works accurately and meets expected deadlines and target dates.
• Ability to communicate effectively with contracting physicians, other ancillary providers and internal departments.
• Compliant with KHS policies and procedures.
EMPLOYEMNT STANDARDS
EDUCATION:
Education: Associate Degree in Nursing from an accredited institution or equivalent required; Bachelor of science (BSN) Preferred.
EXPERIENCE:
• Three (3) years of RN experience in a direct patient care setting preferred.
• One (1) year experience in Utilization Management or QI in a healthcare delivery or managed care setting required.
LICENSURE:
• Possession of a valid California Registered Nursing License and in good standing.
• Certification in Quality Improvement/Assurance highly desired.
**Depending on the duties assigned to this position, certification by the CA Department of Health Care Services (DHCS) as a site reviewer may be required upon completion of required training.
Other: Possession of valid driver’s license and proof of State required auto liability insurance.
Up to 50% driving may be required.
Knowledge of:
• Managed health care and Knox-Keene licensure requirements.
• Applicable State and NCQA standards and regulations pertaining to quality improvement management programs
• HEDIS data collection and analysis.
• Quality improvement study design methods and appropriate quality improvement tools and applications is preferred
• Microsoft Office programs including Word, Excel, and PowerPoint.
Ability to:
• Communicate effectively with physicians, other ancillary providers and internal department leadership and other staff.
• Address interpersonal issues that arise using conflict resolution skills. Problem-solve issues identified with projects, assignments, or processes.
• Write reports and clinical summaries in a clear, succinct, and professional manner.
• Maintain proper documentation and confidentiality.
• Possess effective organizational skills, appropriately prioritizes work and able to work independently.
Kern Health Systems, known as Kern Family Health Care, was established in 1993 as a managed care health plan, and is the largest health plan in Kern County. Kern Health Systems is committed to providing quality health care to our members. It is important to ensure good health through continuity of care by connecting each member to a provider of their choice within our provider network. Our extensive provider network includes the Traditional and Safety-Net Providers that historically delivered care to Medi-Cal recipients and private providers throughout Kern County and some parts of Los Angeles County. We believe good patient/physician relationships and effective preventive care are true indicators of our success. We also offer a continuum of care that extends beyond doctor visits. With a full range of health education classes and Care/Disease Management programs, we provide quality educational and preventive services to the population we serve. We are able to achieve this through partnerships with our providers and community-based organizations within Kern County. The difference is clear: We hold the standard high when it comes to quality health care for our members. Our Missio...n… Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system. As Kern Health Systems continues to move forward, we will continue to uphold our mission of being dedicated to improving the health status of our members through an integrated managed healthcare delivery system. As the healthcare landscape has been transformed, we will pursue tomorrow with community and provider innovation, enhanced member access, and strengthened member health and wellbeing...Together.
