Quality Management Nurse (Must have LVN / RN California License) (Finance)
Overview of the Role:
Alignment Health is seeking a quality management (QM) nurse (Must have RN / LVN California License) to join the quality management team. As a QM nurse, you will measure and evaluate adherence to clinical processes, participate in accreditation / certification activities, and support other quality activities. The QM nurse reports to the senior management of quality management.
Responsibilities:
- Performing internal clinical program auditing, analysis and feedback as needed
- Investigating potential quality of care issues that may affect the quality or safety of the health of members
- Conducting chart review, data collection, program effectiveness and comparative studies
- Assisting with annual quality related projects such as Chronic Condition Improvement Projects, internal evaluation, compliance plans, or Satisfaction Surveys
- Evaluating reports for continued compliance with clinical quality requirements
- Ensuring workflows, policies, procedures, regulatory and accreditation standards are implemented and maintain compliance for clinical programs
- Other duties as requested or assigned
Required Skills and Experience:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Minimum (2) years' experience in quality management, quality improvement, or process improvement
- Strong critical thinking and nursing judgment experience
- Managed care knowledge or experience
- Maintain confidentiality of information between, and among, health care professionals
- Knowledge of CMS guidelines, regulations, NCQA® and HEDIS®
- Familiar with Special Needs Plan (SNP) programs
- Active, unrestricted California License for registered nurse (RN) preferred but a licensed vocational / practical nurse (LVN / LPN) in good standing with quality experience may be considered
- Associate degree or bachelor's degree in nursing, public health administration, or health related field preferred or an equivalent combination of education and experience
- Excellent organizational skills with the ability to manage multiple priorities
- Attention to detail with analytical and problem-solving capabilities
- Able to take initiative and see tasks to completion.
- Computer skills and experience with Microsoft Office suite.
- Excellent written and verbal communication skills
- Problem solving skill sets and analytical ability
- Able to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers
- Experience with the continuous quality improvement process
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
- The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
PAY RANGE: $80,900 - $100,000 ANNUALLY
Depending on skills, experience, and level of licensure
