What are the responsibilities and job description for the Quality Management Nurse Specialist position at UCLA Health Careers?
Description
The Quality Management Nurse Specialist serves as the key resource for the investigation of member complaints, grievances, quality of care and access-related patient issues through collaboration with providers, health plans and other departments. The incumbent will conduct routine as well as ad hoc medical record and office site audits as required. As a member of the QM Team, this position assists with quality improvement studies through data collection, data input and report development. The QM Nurse Specialist will adhere to NCQA, State, Federal and other Regulatory agency standards. Additional areas of responsibility include tracking and trending complaint and grievance data to identify and report aberrant trends.
Key responsibilities include:
- Analyze and resolve complaints/appeals: Gather and organize key information, ensuring a thorough review. Consult with Medical Directors as needed to finalize resolutions.
- Maintain accurate records and compliance: Keep confidential documentation of complaints and grievances, respond promptly to health plan requests, and ensure all actions comply with health plan, state, and federal regulations.
- Review medical records for denied services: Evaluate prospective, concurrent, or past medical records using clinical guidelines to determine medical appropriateness, investigating member history, clinical background, benefits, and eligibility.
- Manage member transfer/termination requests: Track and process requests, prepare formal letters for patients and health plans documenting non-compliance or unacceptable behavior, and oversee the transfer/termination process.
- Support quality management (QM) projects: Assist in initiatives like HEDIS/Pay for Performance, clinical studies, and access surveys by compiling data and producing reports, charts, and graphs to highlight outcomes.
- Prepare and submit regulatory reports: Collect and submit required information for reports to regulatory agencies, health plans, and internal committees as directed by management.
- Conduct audits and ensure compliance: Schedule and perform medical record and facility site audits based on NCQA, CMS, DHS, and health plan standards. Develop corrective action plans, follow up on issues, and generate reports.
- Oversee credentialing and re-credentialing processes: Manage QM activities, ensuring required documentation (site reviews, medical record audits, study participation, and grievance outcomes) is submitted promptly to the Credentialing Oversight Coordinator/Provider Relations unit.
- Assist with health plan audits: Help prepare for audits by ensuring all documentation and processes meet requirements, working with management to implement necessary improvements.
Salary Range: $36.49 - $76.05 Hourly
Salary : $1,000 - $1,000,000
