Job Abstract

The Quality Management Nurse Specialist RN II is responsible for overseeing the clinical aspects for quality improvement projects/activities, which may include but are not limited to the clinical review process for potential quality of care and service issues, regulatory compliance with CMS, DMHC, DHCS, and NCQA.

This position is responsible for ensuring program activities are completed in a high quality and timely manner and ensuring compliance with all regulatory guidelines such as Medicaid (Medi-Cal), Medicare, and the Health Exchange, as well as National Committee for Quality Assurance (NCQA) Accreditation. 

Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management.  
      
Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas.        

Develops and/or maintains relationships with other external organizations to expand key partnerships.        

Creates, maintains and implements training/education and supporting documentation for internal and external clients/customers/members.        

Develops and submits regulatory reports at the time and in the manner required by state or federal agencies such as Centers for Medicare and Medicaid Services(CMS). 

Conducts/ performs clinical review of assigned potential quality issue cases (PQI), and close cases within regulatory timeframe, and presents appropriate cases to the peer review committee for action and resolution

Perform other duties as assigned.

Required:
At least 5 years of clinical experience as an RN in an acute hospital setting.

Preferred:
Experience with regulatory compliance such as CMS, DMHC, DHCS, and NCQA.

At least 5 years of managed care and/or quality improvement experience as an RN in a managed care/ healthcare setting preferably with Medicare ,Medi-Cal, or other government programs. 

Experience in the review of quality of care and service concerns, preferably complaints from member grievance.

Experience in compliance, accreditation, service or quality improvement.

Experience in facilitating workgroups and project management. 

Required:
Must have excellent written and verbal communication and presentation skills.  

Ability to manage projects independently and assume responsibility for successful completion.

Ability to develop and maintain strong working relationships with internal and external clients/ customers /members.

Must have excellent analytical skills, working knowledge of statistics and reporting. 

Must be detail-oriented and effective critical thinking skills. 

Proficient in Microsoft Office (Word, Excel).

Strong interpersonal skills and high level of professionalism.

Ability to work independently and within a team environment.

Preferred:
Knowledge in the community standards of practice, including clinical guidelines.

Preferred:
CPHQ or familiarity with quality improvement methodology such as Lean Six Sigma or Plan-Do-Study-Act.