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QI Nurse, Quality Management - FT/Days (8hr)

Fountain Valley, California

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Join a team of caring, compassionate Nurses at MemorialCare whose dedication has earned them the highly coveted Magnet® recognition for excellence in nursing and patient care across all of our facilities. The Registered Nurse provides a high level of professionalism, compassion and commitment to our patients by providing safe, efficient patient care through the health experience. MemorialCare Nurses exude the highest standards for nursing excellence, quality patient care, professional innovation and inter-professional collaboration.

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Success Profile

What makes a successful RN at MemorialCare? Check out the traits below to see if you have the right mix.

  • Collaborative
  • Communicator
  • Compassionate
  • Flexible
  • Multi-tasker
  • Team player

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Photo of Karen Walker
"I’ve worked at Long Beach Medical Center for almost 20 years, the majority of which has been spent as a bedside RN. With the support of the organization I was able to attain my Bachelor’s and then Master’s Degree by participating in the Tuition Reimbursement program. I’ve always felt one of the best things about Nursing is that I learn something new almost every day. I recently became a Clinical Educator and am finding it incredibly rewarding to not only facilitate education for others, but to continue building my own knowledge base with each new opportunity. These hallways have seen me say goodbye to loved ones, hold my baby for the first time, make life-long friends, and advance my career. My heart is where my home is, and my home is here!"
- Karen Walker, RN, Clinical Educator, Cardiac Monitor Unit

Mission

  • Mission
  • To improve the health and well being of individuals, families and our communities.
  • Vision
  • Exceptional People.
  • Extraordinary Care.
  • Every Time.

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Benefits

  • Healthcare

    Medical, Dental and Vision plans (HMO & PPO) & Flexible Spending Accounts (FSA)

  • Health and Wellness Programs

    MemorialCare is committed to providing an environment and culture that empowers its employees to maintain or improve well-being through our nationally recognized "Good Life" program.

  • Employer Matching 401(K)

    MemorialCare is committed to your financial success and provides the 401(k) Plan to help you save for retirement.

  • Professional Development

    MemorialCare encourages and supports the professional growth of its employees by providing financial assistance to further their education.

  • Paid Time Off

    A fully integrated PTO plan which includes; vacation, sick leave, holidays & personal days.

  • Life and Disability Insurance

    Basic Life/AD&D is an employer paid benefit that is offered to Full-Time employees.

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Responsibilities

Location:

Schedule: Full-time

Shift: Regular

Job Listing:MEM006151

Respond to appeals from the involved health plan within 24 hours for Expedited Appeals and 7 calendar days for Routine Appeals.  Assemble the denial packet response including the cover letter outlining the findings, member’s medical records, a copy of the denied referral request, a copy of the denial letter and rationale for initial decision. Present overturned cases to Medical Director for approval to issue authorization per health plan demand. Log all appeals in to the database for monthly tracking as well as Quarterly Appeals Trending Report to be presented to the Quality Improvement Committee (QIC).

Complete grievance reviews received from the Health Plan, provider or member. Request a response to the involved provider(s) on the same day of receipt or the following day with a specific date.  If no response within 3 days of the requested date, nurse will call the provider’s office staff for status of requested items. After researching and reviewing the case, send a response with medical records if applicable, to the involved health plan within the standard timeframe of five (5) to seven (7) days. Response will include cover letter outlining the findings, provider’s response (medical records from provider and facility) and the medical group’s conclusion regarding the stated grievance. All grievances are tracked by monthly logging and Quarterly Grievance Trending Report presented to Quality Improvement Committee (QIC).Conduct investigation and gather evidence required to complete a thorough review of quality of care issues that involve potential harm to a patient or represent serious deficiencies in the performance of duties. Complete all documentation of unexpected events and communicate according to the policies, procedures and chain of command to determine if a Peer Review intervention is necessary. Analysis of other specific cases, providers, or procedures as requested by the Peer Review Chairperson or case managers. Develop mechanisms and review ongoing tracking results of instances of inappropriate or substandard care for the purpose of identifying trends within practice specialties and by individual provider. Request a specific written corrective action plan from providers. 

Experience

 

  1. Qualified candidate must excel in interpersonal communication, patient centered care, and organization.
  2. Must exhibit communication of complex issues in a concise and condensed manner.
  3. Minimum of three (3) years of experience in acute or managed care setting required.
  4. Knowledge of Federal, State and NCQA requirements as well as DMHC, CMS and DHS preferred.
  5. Experience with ICE language preferred.
  6. Minimum 2 to 5 years of experience handling Health Plan appeals and grievances
  7. Knowledge of CMS and NCQA requirements 

 

 

Education/Licensure/Certifications

 

Minimum of an Associate’s Degree (AA) or equivalent from a two year college or technical school required.

Current Registered Nursing (RN) or Licensed Vocational Nurse (LVN) License in good standing required.

Current CA LVN/RN License 

 

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