QI Nurse Specialist (RN) (PQI)

About the role

We are seeking a QI Nurse Specialist (RN) (PQI) to join our Quality Improvement team. This role requires a Bachelor's degree in nursing with 5 years of experience in patient care, including 2 years in an acute care hospital. The ideal candidate will have access to means of transportation for work away from the primary office approximately 5% of the time required.

Responsibilities

• Participates in the grievance review process and investigations for potential quality of care issues.
• Collects appropriate data and closes cases by preparing and submitting them to the Medical Director and committees for action and closure.
• Ensures grievances/complaints and PQIs are processed in accordance with regulations, compliance standards, and policies and procedures.
• Performs clinical assessments of member complaints and intervenes as needed for urgent clinical issues.
• Reviews clinical cases to identify those that are quality of care and assists with the intake of cases in the department.
• Performs clinical investigations of potential quality issues received from various sources and assesses the criticality of events.
• Maintains the integrity of the departmental database by thoroughly, timely, and accurately entering cases.
• Participates in departmental meetings, trainings, and audits as requested.
• Reviews productivity and timeliness for quality of care grievance reviews and PQIs using reports.
• Fosters and supports a culture of compliance, ethics, and integrity.
• Maintains knowledge of policies and procedures and performs in accordance with applicable regulatory requirements, external laws, and accreditation standards.

Requirements

• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.
• Certification in Case Management (CCM) or Certified Professional in Healthcare Quality (CPHQ).
• Experience in a managed care setting.
• Project management experience.

Qualifications

• Bachelor's degree in nursing.
• 5 years of experience in patient care, including 2 years in an acute care hospital.
• Access to means of transportation for work away from the primary office approximately 5% of the time required.

Skills

• Excellent communication skills.
• Ability to work independently and exercise sound judgment.
• Knowledge of computer systems and job-specific applications.

Benefits

A comprehensive benefits package including a CalPERS pension program and additional retirement packages, a generous PTO program, quality work-life balance, various wellness programs, tuition reimbursement, professional development opportunities, career development opportunities, and flexible scheduling. Employee benefits may vary based on location.

Pay

The pay grade for this role is 313, ranging from $90,820 to $145,312 annually ($43.66 to $69.8615 hourly), with the final salary offered based on education, job-related knowledge and experience, skills relevant to the role, and internal equity among other factors.

Schedule

This position is approved for Full Telework, eligible in California only. Employees may be required to come in to the Main Office in Orange, CA, at least two (2) days per week minimum.