QM Nurse

QM Nurse

 

 

Signal Hill – based MSO has an immediate opening for a QM Nurse position.  The Quality Management Nurse is responsible for all aspect of quality management functions and out of network case management. The person will also cross over with Case Management to manage hospital admissions when Case Management Nurse is not available.  The duties of the Quality Management Nurse is to ensure delivery of cost efficient, appropriate health care services for all members; to ensure members with complex and chronic care needs are addressed; to ensure that medically necessary care is delivered for members that require extensive on-going service; to ensure plan for coordination among all disciplines and to ensure that quality issues are identified and resolved.  At least 2 years prior experience in Quality Management preferred.  Very competitive compensation and benefit packets.  Fax resumes to (562) 216-5420 or email it to ltran@ahcipa.com .

 

Job Description

 

Name and Job Tite:  QM Nurse

 

Reports to: Chief Medical Officer and Chief Operations Officer 

 

 Position Summary:

 

The Quality Management Nurse is responsible for all aspect of quality management functions and out of network case management. The person will also cross over with Case Management to manage hospital admissions when Case Management Nurse is not available.

 

The duties of the Quality Management Nurse is to ensure delivery of cost efficient, appropriate health care services for all members; to ensure members with complex and chronic care needs are addressed; to ensure that medically necessary care is delivered for members that require extensive on-going service; to ensure plan for coordination among all disciplines and to ensure that quality issues are identified and resolved.

 

Specifically, QM Management Nurse is also responsible for the following functions, including but not limited to:

 

I.  Quality Management – Primary Function (65%)

 

§ Prepare material and participate at UM/QM Committee meetings.

 

§ Coordinate with the UM Manager and Case Management on in-patient CCS cases and the management of discharged patients.

 

§ Work with Health Plan Case Managers in managing chronically ill patients and frequent fliers.

 

· Generates and submit quarterly reports and workplan to the Health Plans in required format and within the time frame.

 

· Assess and report on  member and provider satisfaction annually

 

· Report and coordinate of facility site and medical record reviews

 

· Do sentinel event and mortality evaluation

 

· Handles all members and providers grievances and appeals, including coordination and resolutions.

 

· Serve as a liaison with providers and health plans to provide health education programs, such as maintaining class schedule, maintaining matrix of available resources, maintaining log of referred members to programs and provide reporting to the plans

 

· Serve as a liaison with providers and health plans to provide access to cultural and linguistic, such as maintaining a log and reporting to the plan when appropriate.

 

 

II. Out of Network Case Management – Secondary Function (25%)

 

a. Cross over with Case Management Nurse with daily concurrent review activity for assigned IPA by coordinating with hospital Case Managers, Health Plans, Primary Care Physicians, Medical Director, Hospitalists and providers.

 

b. Coordinate and ensure timely discharge planning with appropriate ancillary providers.

 

c. Identify potential CCS eligible conditions and coordinate with CCS Coordinator.

 

d. Identify cases for outpatient Case Management using criteria and support activities.  Coordinate Link Services, Health Education, etc. to ensure member access to supportive care.

 

III. Pay for Performance – (10%)

 

a. Participate in Pay for Performance meetings to maximize incentive received from the health plans.

 

b. Manages initial health assessments and screenings to comply with plan requirements.

 

IV.  From time to time, new projects will be assigned by the COO or CEO