Regulatory & Compliance Quality Management Nurse (Remote) ID-11917
The Regulatory & Compliance Quality Management Nurse is responsible to manage Quality Management (QM) and Health Resource Management (HRM) department functions which focus on Hill Physicians Medical Group compliance with delegated activities including NCQA, state, and federal regulatory requirements, and health plan delegation oversight programs for all regions. Performs operational oversight to systems, processes, and resources used by QI and HRM. Manages the Grievance and Appeals processes. Functions as the primary support person for the peer review process.
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Key Tasks and Responsibilities:
Directs or oversees preparation for all health plan audits and represents Hill Physicians Medical Group at the audits for UM and QM. Acts as the liaison for all UM and QM regulatory and compliance issues.
Establishes QM and HRM standards compatible with health plans, NCQA, state and federal regulatory requirements, and health plan delegation changes by conducting self-monitoring audits to both clinical and non-clinical authorization requests.
Updates, suggests, or develops relevant Hill Guidelines as they relate to audit trends and health plan changes. Delivers training to implement new and or revised P&Ps when appropriate as it relates to above requirements.
Works with the HRM analysts to ensure updated letters are generated by the Authorization system. Troubleshoots and recommends improvements to system issues related to Tapestry, FaxCom, and other authorization related systems to improve compliance and efficiency with authorization processing.
Participates in the testing of system changes, upgrades, service packs, etc. as needed.
Manages the daily workflow for Grievance and Appeals. Maintains compliance with performance standards. Identifies G & A trends and implements process improvements as needed. Works in coordination with HRM analyst to update the authorization system and any tracking and reporting needs.
Prepares corrective action plans (CAP), CAP responses to Health Plans and develops implementation plan to accomplish goals.
Recommends program improvements or corrections as identified.
Manages sub-delegation oversight process for subdelegated arrangements. Directs and develops training for subdelegated vendors as needed.
Collaborate with the operational leads on identified training gaps and needs to ensure compliance with regulatory and delegation standards (Federal, State, Health Plan and NCQA).
Functions as primary support person. Coordinates and participates in the monthly Peer Review Subcommittee (PRSC) meeting. Works closely with medical leadership and legal in case investigation and recommended actions. Maintaining confidentiality of peer review documents and findings.
Follow-up with providers on needed documents within the established timeline and process.
Prepares quarterly PRSC summary reports and other reports needed to support the peer view and QM process. Performs pre-quality checks on new applicants prior to the Membership Committee.
Skills and Experience:
Active CA nursing license, CA driver’s license. Graduation from an accredited school of nursing. BS preferred, certification as QA/UR nurse or related credential or equivalent experience.
Knowledge of NCQA, CMS, DMHC, HEDIS, California Health and Safety Codes, and Milliman, Care Guidelines.
Teaching and training experience in a health care setting.
Policy and procedure writing with emphasis on regulatory guidelines.
Critical thinking skills and analytical experience in utilization and quality management.
Comfortable navigating various system applications. Proficient in Word, Excel, and Outlook.
Management experience in a health care setting.
Salary
$100-120K/year DOE
Please note that this position will have an (up to 8%) annual performance bonus earning potential and offers a full suite of benefits including 6.5% 401k matching.
At Hill Physicians Medical Group, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.
We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!
