Registered Nurse

Payrate : $42.00 - $44.00 / hr.

Summary :

The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue (PQI) allegations or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in or had the potential for harm to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Reviewer, Nurse Experienced will report to the Manager, Clinical Quality Review. In this role, you will be responsible for reviewing PQI cases per department protocols through various levels of review and executing follow up actions.

Responsibilities :

• Analyze quality issues from both internal and external sources
• Thoroughly investigate, apply critical thinking and clinical judgment to appropriately identify quality of care issues
• Determine appropriate level of case review needed which may include escalating cases to a medical director, Peer Review Committee or Credentialing Committee to render a final determination
• Prepare cases for presentation at physician committees as indicated
• Prepare corrective action plan requests for cases where it is deemed necessary for the provider to institute a change in their present practice
• Present and discuss corrective action plan responses with medical director and / or Peer Review Committee
• Manage assigned case load to meet all timeliness metrics
• May perform clinical oversight

Required Skills :

Preferred Skills (nice to have) :

Education Requirements :

Pay Transparency : The typical base pay for this role across the U.S. is : $42.00 - $44.00 / hour . Non-exempt positions are eligible for overtime at a rate of 1.5 times the base hourly rate for all hours worked in excess of 40 in a work week, or as required by state or local law. Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience. Full-time employees are eligible to select from different benefits packages. Packages may include medical, dental, and vision benefits, health savings accounts with qualified medical plan enrollment, 10 paid days off, 3 days paid bereavement leave, 401(k) plan participation with employer match, life and disability insurance, commuter benefits, dependent care flexible spending account, accident insurance, critical illness insurance, hospital indemnity insurance, accommodations and reimbursement for work travel, and discretionary performance or recognition bonus. Sick leave and mobile phone reimbursement provided based on state or local law.

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