QI Nurse Specialist (RN) (PQI)

QI Nurse Specialist (RN) (PQI) CalOptima We are a mission‑driven, community‑based organization that serves member health with excellence and dignity. If you are ready to advance your career while making a difference, we invite you to join our Quality Improvement team. Responsibilities 90% – Clinical Assessment: Develop a thorough clinical review and written report for cases referred for PQI investigations, perform clinical assessments of member complaints and intervene as needed for urgent clinical issues, review clinical cases to identify quality of care issues, perform investigations of potential quality issues from sources, and ensure integrity of the departmental database with thorough, timely and accurate entry of cases. Participate in a mission‑driven culture of high‑quality performance, with a member focus on customer service, consistency, dignity and accountability. Assist the team in carrying out department responsibilities and collaborate with others to support short‑ and long‑term goals for the department. Participate in departmental meetings, trainings and audits as requested. Review productivity and timeliness for quality of care grievance reviews and PQIs using reports. Foster and support a culture of compliance, ethics and integrity. Maintain knowledge of policies and procedures, and perform in accordance with applicable regulatory requirements, external laws and accreditation standards related to business and clinical risk management. 10% – Other: Complete other projects and duties as assigned. Qualifications Bachelor’s degree in nursing plus 5 years of patient care experience, including 2 years in an acute care hospital (or equivalent education and experience). Access to means of transportation for work away from the primary office approximately 5% of the time. Certification in Case Management (CCM) or Certified Professional in Healthcare Quality (CPHQ) is preferred. 2 years of experience in a managed care setting. Project management experience. Current unrestricted Registered Nurse (RN) license to practice in the state of California. Knowledge & Abilities Develop rapport and establish effective working relationships with CalOptima Health leadership, staff and external contacts at all levels. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; be available for evening and weekend events. Organize, be analytical, problem‑solve and possess project‑management skills. Work efficiently in a fast‑paced environment. 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 (Microsoft Office) and job‑specific applications/systems to produce correspondence, charts, spreadsheets and other information applicable to the position. Physical Requirements Ability to visually read information from computer screens, forms and other printed materials. Ability to speak clearly in conversation and general communication. Hearing ability for verbal communication through 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. Ability to lift and move objects, patients and/or equipment weighing 10 to 25 pounds. Benefits Competitive compensation (Pay Grade 313, $90,820 – $145,312). Full Telework – eligible in California only. CalPERS pension program and additional retirement packages. Generous PTO program and quality work‑life balance. Wellness programs. Tuition reimbursement. Work Environment Work is typically indoors and sedentary with variable work hours and occasional travel. The position is offered as Full Telework (located in California) or, if partial telework, requires attendance at the main office in Orange, CA, at least two days per week. CalOptima Health is an equal‑opportunity employer. We make all employment decisions on the basis of merit and prohibit unlawful discrimination. Qualified individuals with disabilities or veteran status may request reasonable accommodations. If you require an accommodation, please contact View phone number on click.appcast.io. #J-18808-Ljbffr