Lead Quality Risk Management - Grievance/Appeals

Join The Riverside Medical Clinic Family

We have been in the community since 1935. Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region. Your passion, inspiration, and talents are invaluable to us and our mission to serve others. Our facility can provide a place for you to thrive and continue your professional development. Quality healthcare is our passion, improving lives is our reward. We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care.

Summary: 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

To perform this job successfully, an individual must be able to perform each essential function 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. Hours: Monday - Friday, 8:30AM - 5:30PM

Education and/or Experience: 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.

Certification, Licenses, and Registrations: Current California LVN License required and CPHQ is a plus.

Essential Functions

1. Prepare Health Plan required reports and coordinate annual audits.

2. Prepare Corrective Action Plans from audits and access issues.

3. Conduct mandatory annual medical record audits on all RMC practitioners.

4. Coordinate annual HEDIS Data Collection Project.

5. Conduct relevant Q.I. studies for both the clinic and surgery center areas and/or any other AAAHC Regulatory preparation/requirements.

6. Perform periodic random mini- surveys at all locations to maintain AAAHC "readiness".

7. Assist Manager, Quality, and/or Regional Director, Quality and/or Medical Director with special projects.

8. Coordinate CPPI (California Physician Performance Initiative).

9. Review/respond to health plan or individual grievances and appeals in a timely manner.

10. Assist with QRMC and MPC preparation

11. Any other responsibilities requested by Manager, Regional Director, and Medical Director.

Benefit Highlights:

Challenging and rewarding work environment.

Competitive compensation and paid time off.

Excellent Medical, Dental, Vision and Life Insurance Plans.

401(K) with company match and discounted stock plan.