QI Nurse Specialist (RN) (Utilization Management)

QI Nurse Specialist (RN) (Utilization Management)

CalOptima

CalOptima Health is seeking a highly motivated an experienced QI Nurse Specialist (RN) (Utilization Management) to join our team. The Quality Improvement (QI) Nurse Specialist for Utilization Management (UM) is responsible for overseeing UM for CalOptima Health's direct network and delegated Health Network teams. The incumbent will be responsible for ensuring standards are met for operational and oversight compliance and UM operations are consistent with regulatory requirements, accreditation standards and CalOptima Health's policies and procedures. The incumbent will be responsible for staying current with regulatory reports, audit requirements (internal and regulatory body) and regulatory requirements from All Plan Letters (APLs) and CCS Number Letters (NLs) for the management of the UM department. The incumbent will interact with other internal CalOptima Health departments, health networks and external agencies.

Position Information:

Department: Utilization Management

Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)

Work Arrangement: Full Telework

**This position is eligible for telework in California.**

Duties & Responsibilities:

85% - Program Support

Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

Independently performs and manages internal UM department audits, drafts corrective action plans (CAPs) if necessary and tracks to closure, presents findings to UM leadership and committee members, identifies opportunities for improvement, makes improvement recommendations to UM leadership and develops and deploys staff training.

Analyzes internal audit findings to develop key performance indicators (KPI) dashboard or other like dashboards.

Serves as subject matter expert (SME) for clinical areas including but not limited to Jiva.

Prepares reports and presents findings in a clear and concise manner, both written and verbal for management review and approval.

Assists to analyze and interpret regulatory requirements and the impact on the UM department based on analysis and interpretation.

Assists with reviewing and responding to Regulatory Affairs and Compliance (RAC) requests including but not limited to a request for validation (RVD).

Develops training materials in reference to clinical decisioning and rationale, inter rater-reliability (IRR), policy and procedure updates, desktop procedure (DTP)updates, regulatory audit findings remediation and changes to regulatory requirements.

Collects and analyzes data for regulatory reports (federal and state mandated), audits and forwards to RAC for final review and submission to the regulatory body including but not limited to the Centers for Medicare & Medicaid Services (CMS), the Department of Health Care Services (DHCS) or the National Committee for Quality Assurance (NCQA).

Evaluates reports for data integrity, accuracy and appropriateness and assists in the timely production of reports.

Participates in internal and external audits including but not limited to gathering and reviewing documents for submission, preparing files consistent with regulatory requirements, reviewing files and identifying areas of potential risk, participating as the driver or presenter at the time of the audit and assisting with CAP/Blue Sheet responses.

Drafts policy and procedure revisions to align with regulatory requirements from entities including but not limited to CMS, DHCS and NCQA and presents changes to committee members.

Assists with the development and oversight of the Utilization Management program and work plan.

10% - Administrative Support

Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

Provides support to committees working on Quality Improvement activities.

Serves as a liaison and resource between CalOptima Health, delegated health networks and external agencies.

Partners with CalOptima Health internal data/reporting teams to meet all reporting and project deadlines.

5% - Completes other projects and duties as assigned.

Minimum Qualifications:

Bachelor's degree in health sciences, nursing, public health, health policy, health care management, public policy administration or a related field required.

3 years of clinical/UM experience required.

2 years of UM experience in an auditor role.

2 years of experience in a health care delivery system, including a health plan, medical group or IPA.

2 years of managed care experience required.

An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Preferred Qualifications:

Master's degree in health sciences or related field

Required Licensure / Certifications:

Current unrestricted Registered Nurse (RN) license to practice in the state of California required.

Knowledge & Abilities:

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

Work independently and exercise sound judgment.

Communicate clearly and concisely, both orally and in writing.

Work a flexible schedule; available to participate in evening and weekend events.

Organize, be analytical, problem-solve and possess project management skills.

Work in a fast-paced environment and in an efficient manner.

Manage multiple projects and identify opportunities for internal and external collaboration.

Motivate and lead multi-program teams and external committees/coalitions.

Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms and other printed materials and information.

Ability to speak (enunciate) clearly in conversation and general communication.

Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.

Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.

Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

There are no harmful environmental conditions present for this job.

The noise level in this work environment is usually moderate.

If located at PACE:

Work is typically indoors in a clinical setting serving the frail and elderly.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

If located in the Community:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

Employee will occasionally work outdoors in varied temperatures.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

About CalOptima Health:

CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto "Better. Together. is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the alliantbenefits.cld.bz/24caloptimacabenguide regarding our comprehensive benefits and wellness package.

IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is May 29, 2024 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.

Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

To apply, please visit: apptrkr.com/5270332

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