Quality Review Nurse - Performance Improvement Job at Emanate Health (Covina)

Performance Improvement Nurse, Quality Indicators

The purpose of the PI Nurse role is to provide and apply clinical knowledge and ...

Location

United States , Boca Raton

Salary:

73860.00 - 104670.00 USD / Year

Baptist Health

Expiration Date

Until further notice

Requirements

Registered Nurse
Advanced Cardiovascular Life Support
Basic Life Support
Associates degree in Nursing or Bachelors degree in Nursing
RN must complete a preceptor class within twelve months of being deemed competent by department leadership for independent practice
5 years acute care experience
Demonstrated proficiency with MS office word and excel
Demonstrates involvement in Performance Improvement activities

Job Responsibility

Provide and apply clinical knowledge and expertise, advanced critical thinking, coaching and teaching skills and knowledge of performance improvement tools, techniques and processes to a variety of federally or state mandated and/or hospital driven processes including medical staff peer review, clinical database coordination, team/task force development and facilitation and maintenance of policies and procedures and continuous accreditation readiness
Demonstrate advanced verbal and written skills, good organizational skills and interpersonal skills including ability to analyze data, manage time, prioritize, communicate effectively, and problem solve

What we offer

Career growth and development opportunities
Comprehensive health and wellness resources
Wellness program that can help employees eliminate their medical plan deductible
Tuition reimbursement
Day shifts

Fulltime

Quality Review Nurse - DOU & NSU - Full Time - Days - 10hr QVH

Provides expertise to the organization in the form of quality management review ...

Location

United States , West Covina

Salary:

54.63 - 84.67 USD / Hour

Emanate Health

Expiration Date

Until further notice

Requirements

BSN preferred.
Minimum of three years of acute care experience.
Excellent customer service skills required.
Experience in Telemetry, DOU, or Neuroscience preferred
California RN license and BLS required.
ACLS required within 90 days of hire or transfer.
NIHSS Stroke Certification required within 90 days of hire or transfer.

Job Responsibility

Provides expertise to the organization in the form of quality management review and performance improvement knowledge.
Supports the hospital units and staff in preparation for surveys, clinical documentation review, regulatory needs and rounding on patients with discharge calls.
Assists in the review process and peer education/correction.

What we offer

Medical
Dental
Vision
401(k)/Retirement Plans
Tuition Reimbursement
Work-Life Balance

Fulltime

Quality Review and Audit Senior Advisor

The Quality Review & Senior Audit Advisor provides enterprise-level quality assu...

Location

United States of America , Bloomington

Salary:

100000.00 - 166600.00 USD / Year

The Cigna Group

Expiration Date

Until further notice

Requirements

Bachelor's degree strongly preferred
clinical, pharmacy, nursing, or healthcare-related background strongly preferred
management experience required, with a demonstrated ability to lead and develop high-performing teams
strong analytical, data management, and technical skills
advanced proficiency with Microsoft Office Suite
excellent verbal and written communication skills, with the ability to explain complex clinical and pharmacy concepts clearly
if you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload

Job Responsibility

Provide expert clinical and pharmacy oversight for quality monitoring and testing across Medicare, Medicaid, and Exchange (HIM) lines of business
apply clinical judgment and pharmacy expertise to assess benefit configurations, clinical rules, and pharmacy setups for accuracy, safety, and compliance
validate pharmacy benefit designs, including formularies, prior authorization criteria, step therapy, quantity limits, and utilization management logic
interpret clinical documentation, policies, and regulatory guidance to ensure correct implementation within systems and operational workflows
lead and co-lead end-to-end clinical and pharmacy benefit testing for new implementations, benefit changes, and remediation initiatives
evaluate clinical program integrity, including medication therapy management, adherence programs, utilization management, and quality initiatives
identify clinical and pharmacy risks, defects, and configuration gaps
document findings and drive resolution through cross-functional collaboration
ensure testing outcomes align with CMS regulations, NCQA standards, and state-specific clinical and pharmacy requirements
serve as a trusted advisor on regulatory interpretation, translating complex clinical and pharmacy guidance into actionable testing and configuration requirements

What we offer

medical
vision
dental
well-being and behavioral health programs
401(k)
company paid life insurance
tuition reimbursement
a minimum of 18 days of paid time off per year
paid holidays

Fulltime

Utilization Management Claims Review Nurse Rn Ii

The Utilization Management (UM) Claims Review Nurse RN II is responsible for con...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of experience in Clinical Nursing
At least 3 years of experience with Medi-Cal and Medicare in a managed care environment
Experience in performing and creating clinical documentation
Experience in regulatory compliance for a health plan
Registered Nurse (RN) - Active, current and unrestricted California License
Knowledge of medical necessity criteria, reimbursement principles, and managed care operation
Working knowledge of clinical policies
Working knowledge of CPT/HCPC Codes, and ICD-10
Proficient in claims processing systems and electronic medical record platforms

Job Responsibility

Perform claims pre-payment review
Conduct comprehensive retrospective reviews
Complete Provider Dispute Review (PDR) clinical evaluations
Apply internal and external clinical policies
Monitor trends related to contested claims and identify potential FWA concerns
Collaborate with internal teams to support payment integrity initiatives
Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions
Maintain productivity and quality standards
Participate in audits, regulatory readiness activities, and quality improvement initiatives
Document review outcomes clearly and accurately

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Utilization Management Clinical Quality Nurse Reviewer RN II

The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purv...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation
Superior verbal and written communication skills
Advanced computer proficiency in both Microsoft Word and Excel
Strong analytical and team building skills
Ability to work independently and be self-directed
Ability to work effectively with diverse team members
Strong problem-solving skills
Ability to multitask and streamline day-to-day operations
Ability to translate regulatory requirements into auditable tools
Registered Nurse (RN) - Active, current and unrestricted California License

Job Responsibility

Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines
Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions
Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation
Works with department leadership to assess for all opportunities related to quality improvements
Compiles and presents quality report cards that measure adherence to quality and regulatory compliance
Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts
Serves as a consultant to the organization's Compliance team on an ad hoc basis
Performs other duties as assigned

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Quality Improvement Coordinator Senior

Coordinates, facilitates, implements and participates in care management and qua...

Location

United States , Aurora

Salary:

41.10 - 61.65 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Bachelor's Degree in Quality Management or related field
Typically requires 5 years of experience in health care or clinical quality improvement
Knowledge of quality improvement principles, project management, and team facilitation
Knowledge of federal, state and external health care regulations and standards and ability to research those regulations
Knowledge of evidence based, best practice resources to promote efficiency and effective outcomes
Knowledge and use of process improvement methods, statistical tools and evidence based, best practice resources
Demonstrates strong problem solving, leadership, conflict mgmt. and team building skills
Knowledge of medical terminology, clinical concepts and disease management
Ability to analyze complex data and communicate sensitive information
Excellent interpersonal, written and verbal communications skills

Job Responsibility

Coordinates, facilitates, implements and participates in care management and quality improvement initiatives/teams across Aurora Health Care in assigned geographical areas
Develops process improvement plans with leadership and departments throughout the organization to analyze, monitor and ensure high levels of quality and performance
Identifies opportunities for improvement, makes recommendations for change, and leads the implementation of best practices to meet established goals
Promotes cross-departmental communication, collaboration, and performance improvement as a means of achieving cost-effective, high quality care
Coordinates, facilitates and implements best practice strategies for assigned patient populations to meet quality and cost goals
Designs and documents assigned projects to demonstrate the quality levels delivered to patients, while applying Aurora's approach to quality. Uses statistical techniques to analyze and display clinical data using measurement tools and systems, as appropriate
Interprets and communicates care management and quality results in a way that the customer understands. Meets individually with providers and staff to assist with problem-solving, recommend and facilitate improvement strategies. Measures and evaluates attainment of goals. Manages multidisciplinary quality improvement teams and projects to support the accomplishment of care management and accreditation (as appropriate) goals
Completes medical record reviews, compares current practice against best practice guidelines and provides recommendations to improve patient care
Provides leadership and consultative services at least quarterly to departments and services within the organization in achieving regulatory, accreditation, and organizational compliance in quality, safety and in performance management and improvement activities. Serves as a resource on external regulatory requirements relative to care management activities
Maintains awareness of and notifies leadership of actual or potential risk situations. Gathers information and provides input regarding risk management issues as delegated by immediate supervisor. Reviews, trends and reports results at least quarterly of quality and care management related third party visits, chart reviews, surveys, and other data to appropriate committees, departments and administration

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Quality Management Nurse

This position is responsible for leading and coordinating the clinical quality r...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

3 years of experience in Managed Care
3 years of Quality Management experience
Bachelor's degree in business, nursing, or related area
Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse

Job Responsibility

Participate in development, implementation and evaluation of Quality Management programs
Investigate Quality of Care Concerns including tracking and root cause analysis
Ensure compliance with Corrective Action Plans and Performance Improvement Projects
Interface with regulatory agencies as necessary to ensure compliance with regulations
Monitor provider performance through administrative data and medical record review
Participate in Quality Management and Peer Review committees
Assist in the development of the Quality Management Program Description
Assist in the development of the Quality Management Work Plan and annual evaluation
Conduct audits of delegated entities as required by regulations
Act as Subject Matter Expert on Quality Management

Fulltime

Quality Management Nurse Specialist RN II

The Quality Management Nurse Specialist RN II is responsible for overseeing the ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of clinical experience as an RN in an acute hospital setting
Must have excellent written and verbal communication and presentation skills
Ability to manage projects independently and assume responsibility for successful completion
Ability to develop and maintain strong working relationships with internal and external clients/ customers /members
Must have excellent analytical skills, working knowledge of statistics and reporting
Must be detail-oriented and effective critical thinking skills
Proficient in Microsoft Office (Word, Excel)
Strong interpersonal skills and high level of professionalism
Ability to work independently and within a team environment

Job Responsibility

Overseeing the clinical aspects for quality improvement projects/activities
Ensuring program activities are completed in a high quality and timely manner and ensuring compliance with all regulatory guidelines
Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management
Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas
Develops and/or maintains relationships with other external organizations to expand key partnerships
Creates, maintains and implements training/education and supporting documentation for internal and external clients/customers/members
Develops and submits regulatory reports at the time and in the manner required by state or federal agencies such as Centers for Medicare and Medicaid Services(CMS)
Conducts/ performs clinical review of assigned potential quality issue cases (PQI), and close cases within regulatory timeframe, and presents appropriate cases to the peer review committee for action and resolution
Perform other duties as assigned

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

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Quality Review Nurse - Performance Improvement

Job Description

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