Loss prevention investigator Jobs in Fairfield, CA

Overview

To work with a dedicated and committed team, the RN Quality Investigator I is responsible for assessing and improving the quality of care provided by the providers serving our members.

Responsibilities

Potential Quality Issue Investigation and Resolution

• Reviews potential quality issues that are referred to the QI department, including a review of allegations / complaints from members and providers that present adverse variation from expected clinician performance, clinical care, or outcome of care, otherwise known as Potential Quality Issues (PQIs).
• Conducts a thorough internal investigation of PQIs (provider performance and / or system issues), including a review of the incident as reported or alleged, including a review of all relevant medical records.
• Obtain responses from provider(s) and appropriate Partnership departments. When appropriate, generate letters to the providers of concern requesting deliberated responses and additional documentation, if indicated.
• Presents a summary of each case at internal PQI team rounds for a secondary review by the CMO or Medical Directors.
• Works collaboratively with the CMO / Medical Directors in the investigation of potential Provider Preventable Conditions (PPCs) and ensures that appropriate notification is sent to appropriate PHC departments and DHCS Audits & Investigations Unit (A&I). Notifies the provider of the result of the potential PPC clinical investigation.
• Upon determination that a PQI case requires a second opinion review by a specialty physician or by a Subject-Matter-Expert (SME), the RN Quality Investigator follows the process of requesting investigational review and responses from the SME.

Peer Review Committee

Documentation

Track and Trend Reporting

Secondary Duties and Responsibilities

Qualifications

Education and Experience

BSN or Bachelors degree in an applicable field, minimum three (3) years clinical experience. Experience in quality improvement or quality management, managed care; facility site review; HEDIS and Title 22 preferred.

Special Skills, Licenses and Certifications

Current California Registered Nurse license required. Knowledge of healthcare total quality management theory, practices, standards and applicable laws and the ability to access data and information using electronic record systems required. Valid California Driver's license required. Knowledge of NCQA / HEDIS standards. Familiarity with business practices and protocols preferred.

Performance Based Competencies

Proficiency in MS Word and Excel. Excellent oral and written communication skills. Ability to facilitate groups and tasks. Excellent planning and organizational skills. Efficient; follows through on commitments. Attention to detail. Flexible and adaptable to competing priorities, strong team player and able to remain calm under pressure.

Work Environment And Physical Demands

Must be able to work in a fast-paced environment and maintain courtesy and composure when dealing with internal and external customers : Ability to prioritize workload and initiate action. Ability to function effectively with frequent interruptions and directions from multiple team members. Standard cubicle workstation with shared common area. Use of telephone, fax, computer and photocopying machine is required. Requires sitting in front of computer equipment and talking on telephone for major portion of the workday. Must be able to move, lift or carry objects varying in size, weighing up to 25lbs. Must be able to operate a vehicle used for company business.

All HealthPlan employees are expected to :

HIRING RANGE :

$103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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