LEAD QUALITY RISK MANAGEMENT LVN - Grievance/Appeals- Full Time

Universal Hospital Services Inc.; Riverside (CA); On-site; USD 45,000 - 65,000; Full time

Benefits offered by this job

Competitive compensation and paid time off

Excellent Medical, Dental, Vision and Life Insurance Plans

401(K) with company match

Discounted stock plan

Job summary

Universal Hospital Services Inc. is looking for a skilled individual to prepare Health Plan reports, coordinate medical record audits, and manage grievances and appeals. The role requires an Associate's degree, a current California LVN License, and 2-3 years of relevant experience in healthcare settings. Key responsibilities include conducting audits, coordinating annual data collection projects, and developing quality initiatives. The position offers a comprehensive benefits package including medical, dental, vision, and a 401(K) plan.

Qualifications

• Two to three years of experience in a healthcare environment.
• Current California LVN License required.
• CPHQ certification is a plus.

Responsibilities

• Prepare Health Plan required reports and coordinate annual audits.
• Conduct medical record audits on all RMC practitioners.
• Review/respond to health plan grievances and appeals in a timely manner.

Skills

Knowledge of patients' rights and responsibilities

Familiarity with electronic health records (EHR)

Skill in coordinating case reviews

Ability to develop and monitor quality initiatives

Education

Associates degree from an accredited college or University

Job description

Responsibilities

Come and join the RMC Family!

We have been in the community since 1935. Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region. Your passion, inspiration, and talents are invaluable to us and our mission to serve others. Our facility can provide a place for you to thrive and continue your professional development. Quality Healthcare is our passion, improving lives is our reward. We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care.

SUMMARY

Prepare Health Plan required reports, Action plans from audits (CAPs), medical record audits, coordinate annual HEDIS Data Collection, conduct relevant QI studies, and coordinate CPPI. Review/respond to grievances and appeals, monthly medication inventory audit, and monitor any other quality indicators. This position will help lead the daily operations of grievances and appeals process ensuring timely investigation and resolution in accordance with CMS, CDPH, and DMHC regulations and guidelines. Assist in HEDIS Data Collection and conducts Quality studies.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

HOURS

Monday - Friday, 830AM - 530PM

EDUCATION and/or EXPERIENCE

Associates degree from an accredited college or University preferred. Two (2) to Three (3) years of experience. Strong knowledge of Patients rights and responsibilities, familiarity with electronic health record (EHR), incident tracking based on grievances and appeals trends, skilled in coordinating case reviews, and ability to develop and monitor quality initiatives strongly preferred.

CERTIFICATION, LICENSES, AND REGISTRATIONS

Current California LVN License required and CPHQ is a plus.

ESSENTIAL FUNCTIONS

Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job’s purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).

1. Prepare Health Plan required reports and coordinate annual audits.
2. Prepare Corrective Action Plans from audits and access issues.
3. Conduct mandatory annual medical record audits on all RMC practitioners.
4. Coordinate annual HEDIS Data Collection Project.
5. Conduct relevant Q.I. studies for both the clinic and surgery center areas and/or any other AAAHC Regulatory preparation/requirements.
6. Perform periodic random mini- surveys at all locations to maintain AAAHC “readiness”.
7. Assist Manager, Quality, and/or Regional Director, Quality and/or Medical Director with special projects.
8. Coordinate CPPI (California Physician Performance Initiative).
9. Review/respond to health plan or individual grievances and appeals in a timely manner.
10. Assist with QRMC and MPC preparation
11. Any other responsibilities requested by Manager, Regional Director, and Medical Director.

Benefit Highlights

• Challenging and rewarding work environment.
• Competitive compensation and paid time off.
• Excellent Medical, Dental, Vision and Life Insurance Plans.
• 401(K) with company match and discounted stock plan.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.