Quality Improvement Specialist

QI Nurse Specialist (RN) (PQI) CalOptima Join Us in this Amazing Opportunity We are a mission driven community‑based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a QI Nurse Specialist (RN) (PQI) and help shape the future of healthcare where you'll be an integral part of our Quality Improvement team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework. For telework: you are required to work within the State of California only; if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. The QI Nurse Specialist for Potential Quality Issue (PQI) will be responsible for participating in handling the organization's quality of care grievance review process and investigations for potential quality of care issues. You'll be involved with the collection of appropriate data and closing cases by preparing and submitting the cases to the Medical Director and committees for action and closure. Additionally, you will ensure grievances/complaints and PQIs are processed in accordance with regulations, compliance standards and policies and procedures. Your Contributions to the Team 90% – Clinical Assessment Participates in a mission driven culture of high‑quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short‑ and long‑term goals/priorities for the department. Develops a thorough clinical review and written report for cases referred for PQI investigations for review. Performs clinical assessments of member complaints and intervenes as needed for urgent clinical issues. Reviews clinical cases to identify those that are quality of care and assists with the intake of cases in the department. Performs clinical investigations of potential quality issues received from sources (members, providers, staff, hotline, etc.) and assesses the criticality of events. Ensures integrity of departmental database by thorough, timely and accurate entry of cases. Participates in departmental meetings, trainings and audits as requested. Reviews productivity and timeliness for quality of care grievance reviews and PQIs through the use of reports. Fosters and supports a culture of compliance, ethics and integrity. Maintains knowledge of policies and procedures and performs in accordance with applicable regulatory requirements, external laws and accreditation standards as they relate to business and clinical risk management. 10% – Other Completes other projects and duties as assigned. Do You Have What the Role Requires? Bachelor's degree in nursing PLUS 5 years of experience in patient care required, including 2 years of experience in an acute care hospital; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. Have access to means of transportation for work away from the primary office approximately 5% of the time required. You’ll Stand Out More If You Possess the Following Certification in Case Management (CCM) or Certified Professional in Healthcare Quality (CPHQ). 2 years of experience in a managed care setting. Project management experience. What the Regulatory Agencies Need You to Possess Current unrestricted Registered Nurse (RN) license to practice in the state of California required. Your Knowledge & Abilities to Bring to this Role Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem‑solve and possess project management skills. Work in a fast‑paced environment and in an efficient manner. 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: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Your Physical Requirements (With or Without Accommodations) Ability to visually read information from computer screens, forms and other printed materials and information. Ability to speak (enunciate) clearly in conversation and general communication. Hearing ability for verbal communication/conversation/responses via 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. Lifting and moving objects, patients and/or equipment 10 to 25 pounds. Ways We Are Here For You You'll enjoy competitive compensation for this role. Our current hiring range is: Pay Grade: 313 – $90,820 – $145,312 ($43.66 – $69.8615). The final salary offered will be based on education, job‑related knowledge and experience, skills relevant to the role and internal equity among other factors. This position is approved for Full Telework (If the position is Telework, it is eligible in California only). A comprehensive benefits package. CalPERS pension program and additional retirement packages. Additional benefits and perks including: A generous PTO program A quality work life balance Various wellness programs Tuition Reimbursement Professional development opportunities Career development opportunitiesFlexible schedule #J-18808-Ljbffr