Quality Review RN : Hospice

Job Description

Primary Duties and Responsibilities

• The Quality Management (QM) Nurse is responsible for preparing, reviewing, and presenting findings on all potential quality management events reported to the department and all grievances submitted to the Medical Director, Health Plan (HP) and/or Quality Management Committee (QMC) based upon department policies and procedures.
• Depending on each Health Plan's reporting requirements, the QM Nurse reviews all submitted grievances, supporting documentation and prepares a response to the Health Plan partners for their review and determination.
• The QM Nurse tracks the activities related to the grievance until the Health Plan releases a final determination.
• The QM Nurse documents all activities in the Quality Management System for monitoring and Committee reporting.
• The QM Nurse participates in any quality management projects as assigned.
• The QM Nurse assists in the coordination and collection of HEDIS medical records, identifies potential gaps in care/quality of care, provides recommendations to the committee on resolving gaps identified and conducts assigned department audits as appropriate.
• The role involves a high level of data collection, intensive patient care review, and implementing process improvement activities.
• This position participates in the QMC by providing the QM activity reports to the committee.
• Other duties as assigned.

Qualifications

Education and Experience

• At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards.
• Must have 2 to 3 years of Quality or Peer review responsibility.
• Bachelor's degree in a health care related field preferred.

License Required

Registered Nurse (RN) in the State of California

About Us

Hoag Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, eleven health centers and a network of more than 1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose Hoag each year.

For over 70 years, Hoag has delivered a level of personalized care that is unsurpassed among Orange County's health care providers. Since 1952, Hoag has served the local communities and continues its mission to provide the highest quality health care services through the core strategies of quality and service, people, physician partnerships, strategic growth, financial stewardship, community benefit and philanthropy.

Hoag offers a comprehensive blend of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes.

Hoag was the highest ranked hospital in Orange County in the 2024-2025 U.S. News & World Report, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California.

To learn more about Hoag's awards and accreditations, visit:

Hoag is an Equal Opportunity Employer and prohibits discrimination and harassment of any kind. Hoag is committed to the principle of equal employment opportunity for all employees and providing employees with a work environment free of discrimination and harassment. Hoag hires a diverse group of people in a manner that allows them to reach their full potential in the pursuit of organizational objectives.

Job Info

• Job Identification 129644
• Job Category Care Management (Acute, Chronic, Behavioral)
• Locations 4041 MacArthur Blvd, Newport Beach, CA, 92660, US
• Remote or Onsite Remote
• Job Schedule Full Time