The Quality Compliance Nurse-CA Only conducts on-site visits, follow-up in-services and participates in corrective action plan completion with individual Primary Care Physicians (PCP) and Participating Provider Groups (PPG) Facility Site and Medical Record Review requirements. The Quality Compliance Nurse travels within Los Angels County. Must be located in or near Los Angeles County. - Demonstrates regular, reliable and predictable attendance. - Conducts facility site and medical record reviews... more details
You could be the one who changes everything for our 26 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: The Quality Compliance Nurse-CA Only conducts on-site visits, follow-up in-services and participates in corrective action plan completion with individual Primary Care Physicians (PCP) and Participating Provider Groups (PPG) Facility Site and Medical Record Review requirements.
The Quality Compliance Nurse travels within Los Angels County. Must be located in or near Los Angeles County.
• Demonstrates regular, reliable and predictable attendance.
• Conducts facility site and medical record reviews with individual PCPs and PPG for Facility Site and Medical Record Review compliance.
• Coordinates, schedules and completes all site reviews and medical record reviews using Health Care Facility Site and Medical Record Review tool.
• Completes site reviews and medical record reviews using the Facility Site and Medical Record Review tool.
• Completes Facility Site and Medical Record Review site tools, containing a confirmation signing by the Primary Care Physician (PCP), and a Corrective Action Plan (AP) report, which includes recommendation for corrections of deficiencies found at the time of the review within agreed upon timeframe.
• Participates in inter-rater reliability (IRR) audits annually and maintains Reviewer Certification status.
• Coordinates and conducts both individual and group in-services for PCPs and PPG’s, providing detailed instruction and assistance for implementation of mechanisms to improve compliance with DHS requirements.
• Addresses and documents Facility Site and Medical Record Review related provider’s issues and stated by individual PCPs and PPGs.
• Communicates managed care concepts, Health Net’s philosophy, policies to PPGs, individual PCPs, PCP staff, fellow employees and the health care community.
• Provides professional courtesy, customer friendly services to contracted practitioners and office staff.
Education/Experience:
Bachelor’s degree in health related field (Hospital Administration, Health Science, etc.) or strong related experience preferred
• Communications or business experience in a health related environment
• Two to three years experience in a managed care environment coordinating programs/seminars for providers
• 1 – 3 Years Clinical Experience preferred
License/Certification:
• RN California License with previous regulatory audit experience preferred
• Facility Site Reviewer Certification
Government Security/Clearance/Citizenship Requirements:
Pay range: $31.77 to $57.16 per hour
This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. The employee may be eligible for bonuses and other forms of compensation.
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.
Pay Range: $31.78 - $57.16 per hour
