Primary Duties and Responsibilities

• The Quality Management (QM) Nurse is responsible for preparing, reviewing, and presenting findings on all potential quality management events reported to the department and all grievances submitted to the Medical Director, Health Plan (HP) and/or Quality Management Committee (QMC) based upon department policies and procedures.
• Depending on each Health Plan’s reporting requirements, the QM Nurse reviews all submitted grievances, supporting documentation and prepares a response to the Health Plan partners for their review and determination.
• The QM Nurse tracks the activities related to the grievance until the Health Plan releases a final determination.
• The QM Nurse documents all activities in the Quality Management System for monitoring and Committee reporting.
• The QM Nurse participates in any quality management projects as assigned.
• The QM Nurse assists in the coordination and collection of HEDIS medical records, identifies potential gaps in care/quality of care, provides recommendations to the committee on resolving gaps identified and conducts assigned department audits as appropriate.
• The role involves a high level of data collection, intensive patient care review, and implementing process improvement activities.
• This position participates in the QMC by providing the QM activity reports to the committee.
• Other duties as assigned.

• At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards.
• Must have 2 to 3 years of Quality or Peer review responsibility.
• Bachelor’s degree in a health care related field preferred.

Registered Nurse (RN) in the State of California

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