This is a Full-Time position, with a Monday-Friday 8:30am-5pm schedule.

This position is currently fully remote and our offices are located at our 4S Ranch offices.

Must be local to San Diego.

Join the Scripps Health team and work alongside passionate caregivers and provide patient-centered healthcare. Receive endless appreciation while you build a rewarding career with one of the most respected healthcare organizations nationwide.

Why join Scripps Health?

AWARD-WINNING WORKPLACE:

• Selected as one of the 100 Best Places to Work for 2024 by Fortune Magazine and the Great Place to Work Institute for the 16th time. A remarkable achievement as only five healthcare organizations nationwide made the list, and Scripps is the sole healthcare provider in California to be recognized.
• Recognized by Newsweek as one of America's Greatest Workplaces for Diversity in 2024.
• Nearly a quarter of our employees have been with Scripps Health for over 10 years.

This RN Quality Coordinator will primarily be responsible for the review, analyzing, preparation and response of appeals, grievances, and potential quality issue.

Responsibilities will include:

vResponsible for the comprehensive research and resolution of the appeals, grievances, possible quality issues from members, provides and related outside agencies to ensure that regulatory timelines are met.

vRequests and reviews medical records, clinical guidelines, notes and/or detailed claims/bills as appropriate, engages other business partners if necessary and formulates a final conclusion within the required timelines in compliance with the required State, Federal and Healthcare guidelines.

vComposes all correspondence including but not limited to acknowledgement letters, final resolution letters or corrective action plans in accordance with regulatory requirements.

vMaintains accurate and timely documentation of appeals, grievance, possible quality issues, and peer review responses including updating appropriate database and/or logs with the required information.

vAble to prepare cases for response to regulatory inquiries and audits.

vPreforms ongoing monitoring of corrective action plans including conducting site audits and follow up audits if necessary.

vAssists with tracking and trending reports and committee material preparation.

vThis is an ideal position for an experienced clinical nurse that can multi-task, independently prioritize work as needed, have strong communication skills, and possess professional-level writing skills.

vThe Quality Coordinator, RN manages publicly reported and other significant quality measures and performance improvement in collaboration with administrative, clinical and physician leadership for their assigned service line.

vPerforms concurrent review of medical records for core measures and other clinical indicators based on established definitions and provides real time feedback and intervention with clinical staff and physicians to ensure optimal quality patient care.

Preferred Education/Experience/Specialized Skills/Certification:

• Experience with appeals and grievances.
• Background in managed care.
• Bachelor's degree strongly preferred.
• Previous experience using Epic.
• Familiarity with Department of Managed Health Care standards as they relate to Performance Improvement and/or Medical Staff Quality/Peer review strongly preferred.

Required Education/Experience/Specialized Skills:

• At least 5 years of recent direct patient care experience or currently holding a coordinator/leadership level role within an acute care setting.
• Requires attention to detail, analytical skills, excellent communication skills.
• Previous experience in quality improvement methods and tools required.

Required Certification/Registration:

*Current RN License required.