QI Nurse Specialist- Facility Site Review (FSR) Nurse Auditor

QI Nurse Specialist- Facility Site Review (FSR) Nurse Auditor

Job Description
Department(s): Quality Improvement
Reports to: Supervisor, Quality Improvement
FLSA: Non-Exempt
Salary Grade: M - $85,000 - $141,086

About CalOptima Health

CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

About the Position

The QI Nurse Specialist will be responsible for performing Department of Health Care Services (DHCS), Facility Site Reviews (FSR) and Medical Record Review (MRR) in compliance with DHCS Medi-Cal Managed Care Division (MMCD). The incumbent will be responsible for auditing health network, CalOptima Health's direct provider offices and designated Healthcare Delivery Organizations (HDO's) to ensure safety, quality and physician compliance with local, state, federal and CalOptima Health's requirements. Additionally, the incumbent will conduct other focused site reviews, as requested by management.

Duties & Responsibilities:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department
• Audits practitioner offices utilizing approved prescribed audit tool for FSR/MRR/ Physical Accessibility Review Survey (PARS).
• Assists practitioner offices and/or health networks for readiness to audit surveys.
• Provides pre-audit and/or post-audit educational sessions.
• Audits health care delivery organizations (skilled nursing facilities, dialysis centers, rehab, home health, etc.) as needed and scheduled, utilizing the appropriate audit tools.
• Documents accurately according to prescribed guidelines per audit tools.
• Maintains accurate and timely site audit files.
• Provides support to internal/external staff and fosters an environment where customer needs (health network, practitioner, etc.) are the primary focus.
• Acts as liaison between provider sites and CalOptima Health to assess and communicate issues and improvement opportunities for plan(s) of action and resolution(s).
• Performs follow-up audits/reviews as generated by initial outcome scoring on FSR/MRR to ensure Corrective Action Plans (CAPs) have been adequately implemented, develops CAP as deemed necessary.
• Completes other projects and duties as assigned.

Experience & Education:

• Bachelor's degree in Health Services, Public Health, Business (with quantitative emphasis), Nursing or other related field required.
• Current, unrestricted Registered Nurse (RN) license to practice in the State of California required.
• 3 years of experience in patient care, health care or managed care setting required.
• 3 years of clinical experience in medical/surgical, ambulatory care, Independent Physician Association (IPA) or medical group environment required.
• 3 years of experience in quality management required.
• Valid driver's license and vehicle or other approved means of transportation, an acceptable driving record and current auto insurance will be required for work away from the primary office 50% of the time or more.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

• Certification by health plan as Certified Site Reviewer.
• Experience in a health care delivery system, including health plan, medical group or hospital management.

Physical Demands and Work Environment:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of job, employee is required to move about the organization and outside the office. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must be able to transport and lift laptop case from location to location. Employee must be able to communicate, particularly for regular phone use and face-to-face interaction. Must have means of transportation for offsite visits to health networks/physician medical groups, local meetings and health care delivery organizations. The Master Trainer is occasionally required to travel to Sacramento for training with the state.

• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Requires travel within local area and occasional long distance travel. While outside, the job requires activity moving to and from physician and provider offices regardless of weather.

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

Job Location: Orange, California
Position Type:

To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4232

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