Lead Quality Risk Management - Grievance/Appeals
Wellington Regional Medical Center
Riverside Medical Clinic Quality Assurance Coordinator
Prepare Health Plan required reports, Action plans from audits (CAPs), medical record audits, coordinate annual HEDIS Data Collection, conduct relevant QI studies, and coordinate CPPI. Review/respond to grievances and appeals, monthly medication inventory audit, and monitor any other quality indicators. This position will help lead the daily operations of grievances and appeals process ensuring timely investigation and resolution in accordance with CMS, CDPH, and DMHC regulations and guidelines. Assist in HEDIS Data Collection and conducts Quality studies.
Qualifications: Associates degree from an accredited college or University preferred. Two (2) to Three (3) years of experience. Strong knowledge of Patients rights and responsibilities, familiarity with electronic health record (EHR), incident tracking based on grievances and appeals trends, skilled in coordinating case reviews, and ability to develop and monitor quality initiatives strongly preferred. Current California LVN License required and CPHQ is a plus.
Essential Functions: Prepare Health Plan required reports and coordinate annual audits. Prepare Corrective Action Plans from audits and access issues. Conduct mandatory annual medical record audits on all RMC practitioners. Coordinate annual HEDIS Data Collection Project. Conduct relevant Q.I. studies for both the clinic and surgery center areas and/or any other AAAHC Regulatory preparation/requirements. Perform periodic random mini- surveys at all locations to maintain AAAHC "readiness". Assist Manager, Quality, and/or Regional Director, Quality and/or Medical Director with special projects. Coordinate CPPI (California Physician Performance Initiative). Review/respond to health plan or individual grievances and appeals in a timely manner. Assist with QRMC and MPC preparation. Any other responsibilities requested by Manager, Regional Director, and Medical Director.
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