Appeals and Grievance ,QI Nurse, Medical Management-FT Day (8hr)

Location: 
MMF-Medical Foundation
Schedule: 
Full Time
Shift: 
Day Job
Job Listing: 
MEM002734
Nurses
Incumbent:
Position Title:
Quality Nurse
Employee ID:
Job Code:
F-2021
Department:
Medical Management
Dept. Number:
875000
Salary Grade:
STF 41
Exempt:
Non-Exempt
Supervisor’s Name:
Title:
Effective Date:
July 2016
Purpose Statement / Position Summary
Provide a summary of the position describing the primary objective of the position (e.g. Why does the position exist). 
Under minimal supervision and in a professional manner, the Quality Nurse performs all job duties to the highest level of customer service and assistance to both internal and external customers of Memorial Care Medical Foundation. This position requires exceptional interpersonal communication, customer service, and organizational skills required.  The quality improvement nurse is required to meet all managed care delegation requirement for this position to ensure compliance with meeting all turnaround times for preservice appeals, grievances and denial letters. 
Essential Functions and Responsibilities of the Job
List of broad job specific functions that employees must be able to do:
  1. Work independently as well as part of a team
  2. Ability to problem solve
  3. Demonstrate initiative and responsibility
  4. Communicate effectively and clearly
  5. Be at work and be on time
  6. Follow company policies, procedures and directives
  7. Interact in a positive and constructive manner
  8.  Prioritize and multitask
Organizational Expectations
Preset goals from section 1 of CAT.
Integrity
Trust
Delivers promised results, expects and helps others to do the same.  Is widely trusted and is seen as direct, truthful and authentic.  Chooses the right path even when it may be uncomfortable or difficult.  Takes ownership if mistakes are made and works to correct the situation. 
Ethics
Doing the right thing even if no one is watching.  At all times acts in a moral, ethical way that is compliant with all laws, regulations and policies governing MemorialCare’s work as a health care provider.
Accountability
Personal Responsibility
Accepts full responsibility for personal behavior and contributes as a team member to complete tasks, resolve problems, and achieve goals. Follows through on commitments. Take responsibility for their actions.
Regulatory Requirements  and Compliance
Complies with regulatory requirements, applicable laws, and policies and procedures set forth by the organization and individual departments. Maintains all license and certification requirements.
Fiscal Responsibility
Effectively manages time and resources to reduce waste and complete individual, team, unit/department, or organizational-wide work activities.
Best Practices
Supports Performance  Improvement  and LEAN
Proactively seeks improvement opportunities to increase effectiveness and efficiency. Supports and embraces necessary change, demonstrates openness to new ideas, processes and technologies.  Works collaboratively to implement new strategies and improve team performance. Consistently implements practices to improve patient safety, customer service and quality care.
Continuous Learning
Pursues both internal and external learning opportunities for self and professional development. Proactively takes responsibility for learning about trends and changes in their given field. Regularly seeks and accepts feedback for development and improvement. Recognizes additional work or duties as an opportunity to grow professionally.
Compassion
Service
Focused on providing the highest level and quality of customer service. Exhibits professionalism, respect and dignity at all times. Demonstrates a personal commitment to understanding, meeting and exceeding the needs of fellow employees, patients, physicians, and guests. Delivers proactive, helpful, courteous and knowledgeable service.
Communication
Practices open and honest communication demonstrating support and empathy. Respectfully asks questions and practices active listening to gain full understanding of diverse perspectives. Maintains the self-esteem and confidence of others. Effectively conveys both written and oral communication to achieve mutual understanding, while appropriately adapting the message, style and tone to accommodate a variety of audiences.
Synergy
Teamwork
Participates as active team member, demonstrating a willingness to engage and accept shared responsibility. Works cooperatively and collaboratively within and across departments to achieve positive results.
Essential Job Outcomes
Section II of the CAT.  Specific job-related responsibilities and duties.
  1. Support the Quality Improvement Program, including proper management of grievances, appeals, internal referrals, member pre-service denial letters, focused quality, and service audits. In addition, the Quality Improvement Nurse supports other QI activities related to HEDIS, medical records audit and access audits. The QI Nurse serves as a liaison for internal and external customers in matters affecting members, providers and other customers. Ensure appropriate resolution of member appeals, grievances and peer review requests in a timely and appropriate manner.
  1. Track and trend incidents of service and clinical quality of care issues and identify opportunities for improvement to present if needed to the QI Medical Director an Peer Review.
  1. Generate meaningful and accurate reports, queries, graphs, and presentations.
  1. Establish and maintain a good working relationship with all providers, health plan contacts, Medical Directors and department manager.
  1. Maintain department compliance with all federal, state, local laws, regulations, accreditation, and other related requirements along with all organizational policies and procedures.
  1. Supports QI Supervisor, QI Manager, QI Director, Medical Director and others within the QI Department and in alignment to the organization’s vision and strategic goals.
  1. Other duties as assigned.
Experience
List the minimum experience, skills, knowledge and abilities required to do the job.
  1. At least 2-5 years managed care experience
  2. 2-5 years clinical experience in a managed care setting
  3. Strong interpersonal communication, customer service, and organizational skills required
  4. Advanced computer proficiency in Microsoft Office : Outlook, Word, Excel and Power Point 
  5. Experience applying evidence-based criteria (i.e.: MCG, Interqual, Hayes); Health plan medical policy / clinical coverage guidelines, CMS (Centers for Medicare and Medicaid Services) coverage policies and with ICE (Industry Collaborative Effort) denial language.
  6. Strong and effective communication skills both in writing and verbally
  7. Knowledgeable of medical terminology
Education
List the education licensures or certifications preferred or required to do the job.
Must be licensed as a registered nurse or licensed vocational nurse
Qualifications: 
Experience
List the minimum experience, skills, knowledge and abilities required to do the job.
  1. At least 2-5 years managed care experience
  2. 2-5 years clinical experience in a managed care setting
  3. Strong interpersonal communication, customer service, and organizational skills required
  4. Advanced computer proficiency in Microsoft Office : Outlook, Word, Excel and Power Point 
  5. Experience applying evidence-based criteria (i.e.: MCG, Interqual, Hayes); Health plan medical policy / clinical coverage guidelines, CMS (Centers for Medicare and Medicaid Services) coverage policies and with ICE (Industry Collaborative Effort) denial language.
  6. Strong and effective communication skills both in writing and verbally
  7. Knowledgeable of medical terminology
Education
List the education licensures or certifications preferred or required to do the job.
Must be licensed as a registered nurse or licensed vocational nurse
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