Quality Management Nurse
Location: Orange, California US
Job Number: 1795
Position Title: Quality Management Nurse
Quality Management Nurse
The Quality Improvement Nurse is responsible for measuring and evaluating adherence to clinical processes, participating in accreditation/certification activities and supporting other quality activities. The Quality Management Nurse reports to the Director of Quality.
(May include but are not limited to)
- Assures that workflows, policies, procedures, regulatory and accreditation standards are implemented adhered to and met for clinical programs.
- Monitors and evaluates clinical programs for desired outcomes;
- Aggregate and analyze audit findings into a reportable format and report to appropriate departments
- Assist with clinical audits
- Conducts activities such as inter-rater reliability studies, chart reviews, data collection, program effectiveness and comparative studies.
- Ensures that potential quality of care issues are addressed appropriately and resolved timely
- Assists with annual quality related projects (Chronic Condition Improvement Projects, internal evaluation, compliance plans, Satisfaction Surveys, etc.).
- Evaluate quarterly/yearly/monthly reports for continued compliance with clinical quality requirements
- Collects, evaluates, and analyzes clinical, functional and program data for patterns or trends in care delivery and reports findings to management.
- Maintains confidentiality of information between and among health care professionals.
- Other duties as requested or assigned.
This position has no direct supervisory responsibility
- Minimum Experience
- Minimum 3-5 years clinical nursing/Case Management or Utilization Management experience
- Managed Care experience
- Knowledge of Medicare Managed Care Plans, NCQA® and HEDIS®.
- Knowledgeable with CMS guidelines and regulations.
- Experience with the application of clinical criteria
- Active, unrestricted State License for Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in good standing
- Associated Degree or bachelor’s degree in nursing or equivalent preferred
- CPHQ, CCM or similar certification a plus
- Proficient in reporting and trending clinical outcomes and CMS required reporting.
- Knowledge of audit processes and applicable state and federal regulations.
- Excellent organizational skills with the ability to manage multiple priorities.
- Work independently and as a part of an integrated team.
- Attention to detail with analytical and problem-solving capabilities
- Ability to take initiative and see tasks to completion.
- Computer skills and experience with Microsoft Office Products.
- Excellent verbal and written communication skills
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
- Problem solving skill sets and analytical ability
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
- Experience with the Continuous Quality Improvement Process
- Essential Physical Functions
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to talk or hear.
- The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
- The employee frequently lifts and/or moves up to 10 pounds.
- Specific vision abilities required by this job include close vision and the ability to adjust focus.
Location City: Orange
Location State: California
Community / Marketing Title: Quality Management Nurse
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.