Salary Range: $47.7200 - $73.3700 /hour. Actual compensation may vary based on geographic location, work experience, skill level, and education.
The Quality Management (QM) Nurse is responsible for preparing, reviewing, and presenting findings on all potential quality management events reported to the department and all grievances submitted to the Medical Director, Health Plan (HP) and/or Quality Management Committee (QMC) based upon department policies and procedures. Depending on each Health Plan’s reporting requirements, the QM Nurse reviews all submitted grievances, supporting documentation and prepare a response to the Health Plan partners for their review and determination. The QM Nurse tracks the activities related to the grievance until the Health Plan release a final determination. The QM nurse documents all activities in the Quality Management System for monitoring and Committee reporting. The QM Nurse participates in any quality management projects as assigned. The QM Nurse assists in the coordination and collection of HEDIS medical records, identify potential gaps in care/ quality of care, provide recommendation to the committee on resolving gaps identified and conduct assigned department audits as appropriate. The role involves a high level of data collection, intensive patient care review, and implementing process improvement activities. This position participates in the QMC by providing the QM activity reports to the committee. Other duties as assigned.
Education & Experience:
At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting. Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards. Must have 2 to 3 years of Quality or Peer review responsibility. Bachelor’s degree in a health care related field preferred.
Licensure Required:
Registered Nurse (RN) in the State of California
About Hoag
Hoag is a nonprofit, regional healthcare delivery system in Orange County, California. Delivering world-class, comprehensive, personalized care, Hoag consists of 1,800 top physicians, 15 urgent care facilities, 10 health and wellness centers, and two award-winning hospitals. Hoag offers a comprehensive blend of health care services that includes seven institutes providing specialized services in the following areas: cancer, digestive health, heart and vascular, neurosciences, spine, women's health, and orthopedics through Hoag's affiliate, Hoag Orthopedic Institute, which consists of an orthopedic hospital and four ambulatory surgical centers. Hoag is the highest-ranked hospital in Orange County by U.S. News & World Report and the only OC hospital ranked in the Top 10 in California, as well as a designated Magnet® hospital by the American Nurses Credentialing Center (ANCC). For more information about Hoag careers, visit careers.hoag.org.
Hoag is an Equal Opportunity Employer and prohibits discrimination and harassment of any kind. Hoag is committed to the principle of equal employment opportunity for all employees and providing employees with a work environment free of discrimination and harassment. Hoag hires a diverse group of people in a manner that allows them to reach their full potential in the pursuit of organizational objectives.