Quality Compliance Nurse Part-Time (CA Only)

Description:

Position Purpose\:

 

Part-Time position

Demonstrates regular, reliable and predictable attendance.

Conducts facility site and medical record reviews with individual PCPs and PPG for Facility Site and Medical Record Review compliance.

Coordinates, schedules and completes all site reviews and medical record reviews using Health Care Facility Site and Medical Record Review tool.

Completes site reviews and medical record reviews using the Facility Site and Medical Record Review tool.

Completes Facility Site and Medical Record Review site tools, containing a confirmation signing by the Primary Care Physician (PCP), and a Corrective Action Plan (AP) report, which includes recommendation for corrections of deficiencies found at the time of the review within agreed upon timeframe.

Participates in inter-rater reliability (IRR) audits annually and maintains Reviewer Certification status.

Coordinates and conducts both individual and group in-services for PCPs and PPG’s, providing detailed instruction and assistance for implementation of mechanisms to improve compliance with DHS requirements.

Addresses and documents Facility Site and Medical Record Review related provider’s issues and stated by individual PCPs and PPGs.

Communicates managed care concepts, Health Net’s philosophy, policies to PPGs, individual PCPs, PCP staff, fellow employees and the health care community.

Provides professional courtesy, customer friendly services to contracted practitioners and office staff.

Qualification: The Quality Compliance Nurse-CA Only conducts on-site visits, follow-up in-services and participates in corrective action plan completion with individual Primary Care Physicians (PCP) and Participating Provider Groups (PPG) Facility Site and Medical Record Review requirements.
Education/Experience\:
Bachelor’s degree in health related field (Hospital Administration, Health Science, etc.) or strong related experience preferred
• Communications or business experience in a health related environment
• Two to three years experience in a managed care environment coordinating programs/seminars for providers
• 1 – 3 Years Clinical Experience preferred

License/Certification\:
• RN California License with previous regulatory audit experience preferred
• Facility Site Reviewer Certification


Government Security/Clearance/Citizenship Requirements\:

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.