Quality Review RN : Hospice

Primary Duties and Responsibilities

• Prepare, review, and present findings on all potential quality management events reported to the department and all grievances submitted to the Medical Director, Health Plan (HP) and/or Quality Management Committee (QMC) based upon department policies and procedures.
• Review all submitted grievances and supporting documentation, and prepare a response to Health Plan partners for their review and determination, based on each Health Plan’s reporting requirements.
• Track grievance activities until the Health Plan releases a final determination.
• Document all activities in the Quality Management System for monitoring and Committee reporting.
• Participate in quality management projects as assigned.
• Assist in the coordination and collection of HEDIS medical records, identify potential gaps in care/quality of care, provide recommendations to the committee on resolving gaps identified, and conduct assigned department audits as appropriate.
• Engage in a high level of data collection, intensive patient care review, and implement process improvement activities.
• Participate in the QMC by providing QM activity reports to the committee.
• Perform other duties as assigned.

Qualifications

• At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards.
• Must have 2 to 3 years of Quality or Peer review responsibility.
• Bachelor’s degree in a health care related field preferred.

License Required

• Registered Nurse (RN) in the State of California

About Us

Hoag Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, eleven health centers and a network of more than 1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose Hoag each year. For over 70 years, Hoag has delivered a level of personalized care that is unsurpassed among Orange County’s health care providers. Since 1952, Hoag has served the local communities and continues its mission to provide the highest quality health care services through the core strategies of quality and service, people, physician partnerships, strategic growth, financial stewardship, community benefit and philanthropy. Hoag offers a comprehensive blend of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes. Hoag was the highest ranked hospital in Orange County in the 2024-2025 U.S. News & World Report, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California. To learn more about Hoag's awards and accreditations, visit: https://www.hoag.org/about-hoag/awards-accreditations/.