The Clinical Grievance RN will be responsible to assist in the development, implementation, monitoring and evaluation of Monarch HealthCare’s overall quality program, which includes clinical, ancillary, support and medical staff compliance with state, federal and health plan laws, statutes, rules, regulations and standards. The QI Nurse will assist in the clinical quality of care review process, the medical record audit process, and analysis of data for presentation to the Quality Management Committee and other interdepartmental committees. The QI Nurse will collaborate with the Quality Manager to establish goals, identify interventions, and implement activities for process improvement in the Quality Department.
- Ensure appropriate resolution of member appeals and grievances in a timely and appropriate manner
- Identify non-compliance with state, federal, and Health Plan standards when investigating appeals and grievances, and intervene as indicated
- Assist in developing clinical medical record and site audit tools and conduct audits to determine provider compliance with established standards
- Work with Network Management staff to ensure provider understanding and compliance with required elements of medical record documentation and other clinical practice standards
- Aggregate and analyze medical record and site audit results
- Communicate audit results to providers along with education about best practices, and maintain that information in the appropriate data bases and/or files
- Assist in the Quality Medical Director review process by gathering pertinent medical information, presenting the cases, and coordinating interventions as advised by the Medical Director
- Assist in the Quality Peer Review process by gathering information for physician peer reviewers
- Track & trend incidents of service and clinical quality of care issues and identify opportunities for improvement
- Create spreadsheets and graphs with relevant QM data, analyze QM data, and create reports and summaries as needed for QM and interdepartmental meetings
- Current and valid, unrestricted California RN license
- 3+ years of clinical experience with an IPA, medical group, hospital, or health plan setting
- Proficient with Microsoft Word, Excel and PowerPoint
- BSN or equivalent
- 1+ years of QM experience
What's the first thing that happens when one of the most successful physician groups in Orange County comes together with a global leader in health care? Opportunity. With Monarch HealthCare joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.SM
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: RN, Grievance, Quality, IPA, Medical Group, Health Plan, BSN, QM, CPHQ, CCM, audit, Irvine, Santa Ana, Garden Grove, CA