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Quality Compliance Nurse - El Centro California
Company: Health Net Location: El Centro, California
Posted On: 04/24/2024
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: The Quality Compliance Nurse-CA Only conducts on-site visits, follow-up in-services and participates in corrective action plan completion with individual Primary Care Physicians (PCP) and Participating Provider Groups (PPG) Facility Site and Medical Record Review requirements. - Demonstrates regular, reliable and predictable attendance.
- Conducts facility site and medical record reviews with individual PCPs and PPG for Facility Site and Medical Record Review compliance.
- Coordinates, schedules and completes all site reviews and medical record reviews using Health Care Facility Site and Medical Record Review tool.
- Completes site reviews and medical record reviews using the Facility Site and Medical Record Review tool.
- Completes Facility Site and Medical Record Review site tools, containing a confirmation signing by the Primary Care Physician (PCP), and a Corrective Action Plan (AP) report, which includes recommendation for corrections of deficiencies found at the time of the review within agreed upon timeframe.
- Participates in inter-rater reliability (IRR) audits annually and maintains Reviewer Certification status.
- Coordinates and conducts both individual and group in-services for PCPs and PPG's, providing detailed instruction and assistance for implementation of mechanisms to improve compliance with DHS requirements.
- Addresses and documents Facility Site and Medical Record Review related provider's issues and stated by individual PCPs and PPGs.
- Communicates managed care concepts, Health Net's philosophy, policies to PPGs, individual PCPs, PCP staff, fellow employees and the health care community.
- Provides professional courtesy, customer friendly services to contracted practitioners and office staff.
- Performs other duties as assigned
- Complies with all policies and standardsEducation/Experience: Bachelor's degree in health related field (Hospital Administration, Health Science, etc.) or strong related experience preferred
- Communications or business experience in a health related environment
- Two to three years experience in a managed care environment coordinating programs/seminars for providers
- 1 - 3 Years Clinical Experience preferred
License/Certification: |
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