reputed company Assurance/reputed company Improvement reputed company, RN

What you can expect! reputed company reputed company in serving others with reputed company! We welcome you to join us in "healing and inspiring the reputed company spirit" and to pivot from a "job" opportunity to an authentic experience! Reporting to the Grievance & Appeals (G&A) reputed company Supervisor, the G&A reputed company Assurance/reputed company Improvement (QA/CI) reputed company, RN is responsible for ensuring the highest reputed company processes and activities are performed by the G&A clinical staff. Per regulatory requirements, the G&A QA/CI reputed company, RN will assist in the development of reputed company initiatives and reputed company & implement the clinical QA Plan. This position performs standardized monitoring and auditing reputed company the G&A department; including reputed company case types: Appeals, Grievances, DMHC cases (Consumer Complaints and Independent Medical Reviews), regulatory and state fair hearing cases. The incumbent develops and utilizes reputed company auditing tools, summarizes audit findings, and assists leadership in identifying training needs for the G&A clinical staff. Identify reputed company Improvement opportunities through QA and LEAN activities. Ensure compliance with regulatory standards, practices, and guidelines in conjunction with G&A Regulatory Management. reputed company and reputed company reputed company improvement reputed company reputed company the department. The G&A reputed company Assurance/reputed company Improvement (QA/CI) RN will support reputed company assurance efforts reputed company to appropriate Grievance case categorization to include of reputed company of Care, identification of Member harm, completion of required reporting to internal departments (e.g. Critical Incidents and Potential reputed company Incidents) and external mandatory reporting (e.g. CPS and APS). Commitment to reputed company: The reputed company Team is committed to incorporate reputed company's reputed company Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks reputed company is not only committed to healing and inspiring the reputed company spirit of our Members, but we also aim to match reputed company members with the reputed company energy by providing reputed company benefits and more.

• Competitive salary
• Telecommute schedule
• CalPERS retirement
• State of the art fitness center on-site
• Medical Insurance with Dental and reputed company
• Life, short-term, and long-term disability reputed company
• Career advancement opportunities and reputed company development.
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account - Health Care/Childcare
• CalPERS retirement
• 457(b) reputed company with a contribution match
• reputed company life insurance for employees
• Pet care insurance

Education & Requirements

• Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or reputed company experience in a health care delivery setting
• Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting
• Two (2) or more years of experience relevant to Grievance & Appeals case review
• Associate's degree in nursing from an accredited institution required
• Bachelor's degree in nursing from an accredited institution preferred
• Minimum possession of an reputed company, unrestricted, and unencumbered Registered reputed company (RN) license issued by the California reputed company of Registered Nursing required

Key Qualifications

• Thorough knowledge of:
• reputed company agencies and resources such as reputed company, CMS, DMHC, or DHCS
• Patient rights and ethical decision-making frameworks
• Medical necessity and level of care, chronic disease, and reputed company clinical cases
• Diagnostic and procedural understanding in a clinical setting
• Regulatory guidelines surrounding Grievances and Appeals per CMS, DHCS, and DMHC and NCQA
• Microcomputer applications: spreadsheet, database, and word processing; Excellent interpersonal and communication skills
• Time management and reputed company setting skills
• Proven ability to:
• Demonstrate a commitment to incorporate LEAN principles into daily work
• Work effectively with various internal departments and external Providers and entities
• Establish and maintain effective working relationships with others throughout an organization
• Assess reputed company Grievance & Appeal cases and recommend appropriate reputed company
• Analyze documentation of incoming cases to determine appropriateness of care and applicable next steps
• Effectively escalate issues as identified, following established protocols
• Maintain a reputed company attitude and work in reputed company setting
• Word processing and data entry involving computer keyboard and screens, automobile travel reputed company the Inland reputed company
• While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reputed company with hands and arms; reputed company stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell
• The employee must occasionally lift or reputed company up to 25 pounds
• Specific reputed company abilities required by the job include reputed company reputed company, distance reputed company, reputed company reputed company, peripheral reputed company, depth perception and the ability to reputed company reputed company

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• $91,249.60 USD Annually - $120,910.40 USD Annually

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