To work with a dedicated and committed team, the site review inspections team, to oversee and
implement Site Reviews, provide education to provider sites and to assess and improve the
quality of care delivered by providers. Types of providers reviewed include, but not limited to,
Primary Care Physicians, Obstetrics, Palliative Care and Private Duty Nursing.

• Performs Facility Site Reviews per contractual requirements (specific to the type of review conducted).
• Performs Medical Record Review per contractual requirements (specific to the type of review conducted).
• Provide education to site’s providers and staff as needed, to help with overall improvement and compliance.
• Works closely with sites to disseminate QI information and offer technical assistance to correct deficiencies. Monitors provider’s progress towards meeting set goals.
• Implementation of ongoing and focused monitoring activates to detect adverse health outcomes and other related issues
• Refers cases for appropriate peer review when established criteria is not met.
• Assist in the investigation of potential quality issues identified at the provider level via a variety of available identification tools.
• Participates in monthly Peer Review Committee, while ensuring confidentiality of peer review records and process.
• Assists in data collection and analysis for review of the appropriate committee.
• Facilitates or participates in improvement teams or committees, as assigned.
• Participates in and leads special projects and assignments, as required.
• Active involvement in HEDIS abstractor training and improvement efforts
• Considerable travel required to all contracted facilities to conduct site reviews and provider educations

Secondary Duties and Responsibilities

• Provides clinical support to the project coordinators, project managers and/or analytical staff.
• Maintains current knowledge of NCQA accreditation; US Center for MediCal and Medicaid services and California Department of Healthcare Services requirements and Health plan's' compliance related to Quality Measurement and Improvement, Site review, Peer Review and Credentialing.
• Collects, coordinates and monitors QI activities that impact other departments within the health plan. These include credentialing information, member complaints, appeals and grievances, collection and investigation of Potential Quality Issues peer review.
• Other duties as assigned

Finish

All Healthplan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the Healthplan’s policies and procedures as they may from time to time be updated.

HIRING RANGE:

$103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, education factors and the requirements and conditions listed in this job description are representative only and not exhaustive 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, or work environment change.