Nurse RN 3

TALENT Software Services; California (MO); Remote; USD 80,000 - 105,000; Full time

Job summary

TALENT Software Services is seeking a Clinical Quality Reviewer to join our CA-based remote team. You will review PQI allegations and coordinate multi-level reviews, applying clinical judgment to determine escalation paths and final determinations.

Responsibilities include analyzing quality issues from internal and external sources, preparing cases for physician committees, and developing corrective action plans. Strong communication and timeliness are essential.

Qualifications

• Nursing degree (Associate or Bachelor's).
• CA RN license (current and unencumbered).

Responsibilities

• Analyze quality issues from both internal and external sources
• Thoroughly investigate, apply clinical judgment to identify quality of care issues
• Determine appropriate level of case review including escalation to medical director or committees
• Prepare cases for presentation at physician committees as indicated
• Prepare corrective action plan requests for cases requiring changes in practice
• Present and discuss corrective action plan responses with medical director/committee
• Manage assigned case load to meet timeliness metrics
• May perform clinical oversight

Skills

Organizational skills

Health plan/IPA experience

Clinical knowledge

Education

Associate's or Bachelor's degree in Nursing

Tools

Microsoft Office

Excel

Adobe Acrobat

Job description

Day to Day Responsibilities

The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue (PQI) allegations or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in or had the potential for harm to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Reviewer will report to the Manager, Clinical Quality Review. In this role, you will be responsible for reviewing PQI cases per department protocols through various levels of review and executing follow up actions.

• Analyze quality issues from both internal and external sources
• Thoroughly investigate, apply critical thinking and clinical judgment to appropriately identify quality of care issues
• Determine appropriate level of case review needed which may include escalating cases to a medical director, Peer Review Committee or Credentialing Committee to render a final determination
• Prepare cases for presentation at physician committees as indicated
• Prepare corrective action plan requests for cases where it is deemed necessary for the provider to institute a change in their present practice
• Present and discuss corrective action plan responses with medical director and/or Peer Review Committee
• Manage assigned case load to meet all timeliness metrics
• May perform clinical oversight

Required Skills (top 3 Non-negotiables)

• Organizational/computer skills/detail oriented
• Health plan/IPA experience in a remote environment
• Extensive clinical knowledge and experience, including in hospital setting - including behavioral health for occasional coverage needs

Preferred Skills (nice To Have)

• Previous quality review experience
• Previous UM or CM experience
• Excellent communication/case presentation skills

Disqualifiers/Dislikes on Resumes

• Lack of remote work experience; spelling/formatting/grammatical errors

Education Requirements

• Associate's or Bachelor's degree in Nursing

Required Testing

• None

Software Skills Required

• Microsoft Office, including ability to manage Excel spreadsheets; Adobe Acrobat

Required Certifications

• Current unencumbered CA RN license