Under the general supervision of the Director of Quality and Senior Quality Improvement Nurse, the Quality Review Nurse has the responsibility for collecting and reviewing medical records to determine quality process compliance, health plan enrollee medical condition outcomes and/or potential quality of care issues. The Quality Review Nurse must be able to keep accurate records, manage data and respond appropriately both verbally and in writing to internal audiences, external professional staff and regulatory agencies. This position may be eligible to work remotely 1-3 days per week under the direct supervision of the Chief Medical Officer following completion of working full time on site for 3 months. The Quality Review Nurse will also be assigned to visit with Facility Site Review.  

Principal responsibilities include:

• Healthcare Effectiveness Data and Information Set (HEDIS) Medical Record Review: ensure accurate collection abstraction, over reading and reporting of HEDIS medical record data. Ensure medical record reviews are in compliance with the National Committee for Quality Assurance (NCQA) HEDIS specifications. Ensure accurate translation of these medical record data elements to appropriate software or database system. Manage databases related to HEDIS data collection, abstraction and over-reading. Communicate with External Quality Review Organizations (EQROs) throughout HEDIS process. • Potential Quality Issues: Identify, analyze and resolve potential quality of care and service issues (PQIs). Assign a corrective action plan (CAP) to providers or practitioners when quality issues arise. Maintain accurate summary data related to PQI outcomes. Conduct Interrater Reliability for PQIs performed by other staff nurses. • Facility Site Review: Using state applied tools, conduct on-site surveys of facilities. Use clinical skills and judgement, determine medical record completeness, assess facility adherence to regulations and assign corrective actions when warranted. • Meet productivity, work quality and work product goals as set by management. • Support other Quality Improvement efforts as needed.  

ESSENTIAL FUNCTIONS OF THE JOB • Conduct HEDIS Medical Record Review • Investigate Potential Quality Issues • Perform Facility Site Reviews • Maintain small to medium data tables  

PHYSICAL REQUIREMENTS • Constant and close visual work at desk or computer. • Constant sitting and working at desk. • Extensive data entry using keyboard and/or mouse. • Frequent use of telephone headset. • Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. • Frequent lifting of folders and various other objects weighing between 0 and 30 lbs. • Frequent walking and standing. • Frequent driving of automobiles.  

MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO:

• Current, unrestricted Registered Nursing (RN) license in the state of California. • Experience navigating multiple electronic health record systems.  

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum of 2 years of direct patient care experience. • 3 years of health plan experience which can include HEDIS medical record review abstraction, Facility Site Review, PQI review and investigation, and/or claim review for medical necessity.  

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Ability to manage small to medium data tables. • Ability to type up to 30 WPM. • Familiarity with Microsoft Office Suite. • Excellent written and verbal communication skills. • Excellent customer service skills.  

Pay Range: $77,710 - $116,570/annually