Under the direction of the Quality Improvement Manager, the QI Nurse I will assist in clinical activities related to monitoring, assessing and improving performance in ambulatory and inpatient health care delivery or health care related services to Kern Health Systems (KHS) membership. The QI Nurse will assist in the implementation of the KHS QI Program Plan and communicate with contracted providers regarding studies, and will participate in facility site reviews, record reviews, chart abstractions and copying records as part of the general QI reporting process which includes data collection, tabulation and report writing.
This position is responsible for assigned Quality Improvement functions for a Knox-Keene
Licensed health maintenance organization (HMO).
MAJOR DUTIES AND RESPONSIBILITIES
Assist in the implementation of the QI Program Plan and Program Workplan;
Performs QI activities related to State required Quality requirements
Serves as knowledge expert for QI activities
Achieves State certification as a facility site reviewer and conducts facility site reviews for credentialing and re-credentialing of practitioners and providers as needed. Certification is provided through KHS;
Participates in record reviews/abstractions/copying;
Prepares and reports physician specific findings to the Director of QI;
Assists in problem identification, data analysis, conclusions, recommendations, and action plans;
Monitors and analyzes outcomes to ensure goals, objectives, outcomes, and regulatory requirements are met;
Assist in preparation of reports for committees;
Assists in activities to prioritize QI initiatives;
Ensures that documentation produced and/or processed complies with State and Federal regulations;
Assists with training for new employees;
Assists with internal QI investigations such as records reviews for member complaints involving possible Quality of Care issues
Assists in problem identification, data analysis, conclusions, recommendations, action plan design, follow-up and tracking.
Performs all job functions in a safe manner;
Provides input in support of State and Federal requirements as it pertains to the mandated managed care accountability set measures;
Maintains the confidentiality of records and reports for both KHS members and contracted providers;
Performs in-depth medical records reviews as needed and is able to write a professional, clinical summary;
Knowledge of acute care nursing principles, methods, and commonly used procedures;
Knowledge of medical terminology, hospital routine; and commonly used medical equipment;
Knowledge of acute hospital organizations and inter-relationships of various clinical and diagnostic services;
Ability to effectively evaluate medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans;
Ability to assess and judge the clinical performance of physicians and other health professionals;
Thorough knowledge of health care delivery systems;
Knowledge of State and Federal managed care regulatory requirements;
Ability to read, interpret and apply written regulations, guidelines and other materials;
Strong analytical, assessment and problem-solving skill;
Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS;
Ability to use tact and diplomacy to diffuse emotional situations;
Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;
Intermediate skills in Word, Excel, PowerPoint, and Outlook, with basic ability to enter data into and navigate through a database;
Ability to commit to and facilitate an atmosphere of collaboration and teamwork;
Knowledge of provider documentation requirements and governmental regulations affecting reimbursement;
Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information;
Self-directed, with proven ability to work independently with minimum supervision;
Uses appropriate judgment and asks questions and seeks assistance appropriately;
Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.
Demonstrated ability to multi-task and complete assignments on a timely basis;
Strong attention to detail; works accurately and meets expected deadlines and target dates;
Ability to communicate effectively with contracting physicians, other ancillary providers and internal departments;
Education: Associate Degree in Nursing from an accredited institution or equivalent required; Bachelor of science (BSN) Preferred.
Three (3) years of RN experience in a direct patient care setting preferred;
One (1) year experience in Utilization Management or QI in a healthcare delivery or managed care setting required.
Possession of a valid California Registered Nursing License and in good standing;
**Depending on the duties assigned to this position, certification by the CA Department of Health Care Services (DHCS) as a site reviewer may be required upon completion of required training.
Other: Possession of valid driver’s license and proof of State required auto liability insurance. Up to 50% driving required.
Visit our careers page at: kernhealthsystems.com
Internal Number: 1562
About Kern Health Systems
Kern Health Systems, known as Kern Family Health Care, was established in 1993 as a managed care health plan, and is the largest health plan in Kern County. Kern Health Systems is committed to providing quality health care to our members. It is important to ensure good health through continuity of care by connecting each member to a provider of their choice within our provider network. Our extensive provider network includes the Traditional and Safety-Net Providers that historically delivered care to Medi-Cal recipients and private providers throughout Kern County and some parts of Los Angeles County.
We believe good patient/physician relationships and effective preventive care are true indicators of our success. We also offer a continuum of care that extends beyond doctor visits. With a full range of health education classes and Care/Disease Management programs, we provide quality educational and preventive services to the population we serve. We are able to achieve this through partnerships with our providers and community-based organizations within Kern County. The difference is clear: We hold the standard high when it comes to quality health care for our members.
Ou...r Mission… Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system. As Kern Health Systems continues to move forward, we will continue to uphold our mission of being dedicated to improving the health status of our members through an integrated managed healthcare delivery system. As the healthcare landscape has been transformed, we will pursue tomorrow with community and provider innovation, enhanced member access, and strengthened member health and wellbeing...Together.