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Quality Investigator
Quality InvestigatorPartnership HealthPlan of California • Fairfield, CA, US
Quality Investigator

Quality Investigator

Partnership HealthPlan of California • Fairfield, CA, US
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Overview

To work with a dedicated and committed team, the RN Quality Investigator I is responsible for assessing and improving the quality of care provided by the providers serving our members.

Responsibilities

  • Potential Quality Issue Investigation and Resolution : Reviews potential quality issues referred to the QI department, including allegations / complaints from members and providers that present adverse variation from expected clinician performance, clinical care, or outcome of care (Potential Quality Issues - PQIs).
  • Conducts a thorough internal investigation of PQIs (provider performance and / or system issues), including review of the incident as reported or alleged and all relevant medical records.
  • Obtains responses from providers and appropriate Partnership departments. When appropriate, generates letters to the providers of concern requesting deliberated responses and additional documentation, if indicated.
  • Presents a summary of each case at internal PQI team rounds for secondary review by the CMO or Medical Directors.
  • Collaborates with the CMO / Medical Directors in the investigation of potential Provider Preventable Conditions (PPCs) and ensures appropriate notification to PHC departments and the DHCS Audits & Investigations Unit (A&I). Notifies the provider of the result of the potential PPC clinical investigation.
  • When a second opinion review is required from a specialty physician or SME, follows the process of requesting investigational review and responses from the SME.

Peer Review Committee

  • Ensures case files selected for review are complete with all required documentation for review.
  • Participates in case discussions and provides additional information as needed.
  • Refers cases to the Credentialing Committee as recommended by the Peer Review Committee.
  • Assists the CMO / Medical Directors in Focus Review activities as determined by the Peer Review Committee or Partnership policy.
  • Generates a Corrective Action Plan as recommended by the Peer Review Committee and follows up with the provider to ensure CAP is implemented and completed.
  • Generates a case closure letter to the provider or facility when appropriate.

    • Documentation

  • Ensures PQI cases are processed and closed within the specified timeframe.
  • Documents cases in the PQI database SUGARCRM and stores related hard-copy documentation securely in the QI department.
  • Participates in Inter-Rater Reliability (IRR) to ensure appropriate case reviews and evaluate the reliability of the PQI review process.

    • Track and Trend Reporting

  • Provides feedback on identified trends and data in support of the Member Safety Quality Investigations team reporting to Internal Quality Improvement (IQI), QUAC, and the Department of Health Care Services (DHCS).

    • Secondary Duties And Responsibilities

  • Assists in identifying and recommending appropriate interventions in QI activities.
  • Provides clinical support to Project Coordinators and / or Analytical staff.
  • Participates in HEDIS and other special projects as required.
  • Educates health plan staff on quality improvement aspects.
  • Maintains current knowledge of NCQA accreditation, CMS, and DHCS requirements and health plan compliance related to Quality Measurement and Improvement, Site Review, Peer Review, and Credentialing.
  • Collects, coordinates, and monitors QI activities affecting other departments, including credentialing information, member complaints, appeals and grievances, and Peer Review Committee determinations.
  • Participates on improvement teams as assigned by leadership.

    • Qualifications

    Education and Experience

    BSN or Bachelor's degree in an applicable field, minimum three (3) years clinical experience. Experience in quality improvement or quality management, managed care; facility site review; HEDIS and Title 22 preferred.

    Special Skills, Licenses and Certifications

    Current California Registered Nurse license required. Knowledge of healthcare total quality management theory, practices, standards and applicable laws. Ability to access data using electronic record systems. Valid California Driver's license required. Knowledge of NCQA / HEDIS standards. Familiarity with business practices and protocols preferred.

    Performance Based Competencies

    Proficiency in MS Word and Excel. Excellent oral and written communication skills. Ability to facilitate groups and tasks. Excellent planning and organizational skills. Detail-oriented, adaptable to competing priorities, strong team player, and able to remain calm under pressure.

    Work Environment And Physical Demands

    Fast-paced environment; ability to prioritize workload, function with frequent interruptions, and interact with multiple team members. Standard cubicle workstation with shared areas. Requires sitting and computer use for major portions of the day. Must be able to move or lift objects up to 25 lbs. Must be able to operate a vehicle used for company business.

    EEO and Company Policies

  • All HealthPlan employees are expected to provide the highest possible level of service to clients.
  • Promote teamwork and cooperative effort among employees.
  • Maintain safe practices; and
  • Abide by HealthPlan policies and procedures, as they may be updated.

    • HIRING RANGE : $103,059.95 - $133,977.94

    IMPORTANT DISCLAIMER NOTICE : The duties, responsibilities, and requirements listed are representative and not exhaustive. The employer reserves the right to revise this description at any time.

    Location notes : Fairfield, CA; Walnut Creek SIU Investigator; Vallejo, CA; Sonoma, CA.

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    Investigator • Fairfield, CA, US