QUALITY COORDINATOR, RN - Performance Improvement (4S) - Full Time - Day in San Diego, CA at Scripps Health Plan Services -4S Ranch

Date Posted: 2/20/2018

Job Snapshot

Job Description

Coordinates appeals, grievances, and peer review processes.  Complies with all State, Federal and Health Plan requirements for correspondence to communicate Appeal & Grievance (A&G) and Utilization Management (UM) decisions to include denials to members and providers as they relate to the A&G.  Abstracts records based on established indicators of the patient peer review; facilitates the peer review process, ongoing performance review and decision support for patient peer review. Attention to detail and solid clinical skills ensure the quality processes aligns with the utilization management processes and all regulatory compliance requirements are met.
Keywords: RN nurse performance improvement utilization management


Job Requirements

Required Education/Experience/Specialized Skills: Minimum 5 years of experience in healthcare environment or 5-7 years of equivalent managed care regulatory experience related to Appeals, Grievances, Clinical Quality Coordinator, Risk Management, Peer Review and/or Health Service Management. Requires attention to detail, analytical skills, excellent communication skills and intermediate computer skills. Previous experience in quality improvement methods and tools required. Knowledge of Core Measures or other publicly reported quality metrics required. Familiarity with Joint Commission standards as they relate to Performance Improvement and/or Medical Staff Quality/Peer review strongly preferred.

Required Certification/Registration: Current CA RN license required.

Preferred Education/Experience/Specialized Skills/Certification: Training and application of MIDAS or like-data based strongly preferred. Bachelors degree strongly preferred.

Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with disability.