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.

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-Experts (SME), the RN Quality Investigator follows the
  process of requesting investigational review and responses from the SME.

Peer Review Committee

• Ensures that case files selected for review at the Peer Review Committee meeting are
  complete, with all required documentation available for review.
• Actively participates in case discussions and provides additional information as
  needed.
• Refers cases to the Credentialing Committee as recommended by the Peer Review
  Committee.
• Assists the CMO/.Medical Directors in Focus Review activities as determined by the Peer
  Review Committee or Partnership policy.
• Generates a request for a Corrective Action Plan as recommended by the Peer Review
  Committee and performs follow-up with the provider to ensure the CAP is implemented
  and completed.
• Generates a case closure letter to the provider or facility when appropriate.

Documentation

• Ensures that PQI cases are processed and closed to completion within the specified
  timeframe.
• Ensures that cases are documented in the PQI database SUGARCRM, and all hard copy
  related documentation is kept in a secure file cabinet in the QI department where only
  designated personnel have access to these files.
• Participates in the Inter-Rater Reliability (IRR) process to ensure cases are appropriately
  reviewed and to ensure that the reliability of the PQI case review process can be evaluated.

Track and Trend Reporting

• Provides feedback on identified trends and other data in support of the Member Safety
  Quality Investigations team reporting to Internal Quality Improvement (IQI) and Quality
  Utilization Advisory Committee (QUAC), as well as to the Department of Health Care
  Services (DHCS).

Secondary Duties and Responsibilities

• Assists in the identification and recommendation of appropriate interventions in
  QI activities
• Provides clinical support to the Project Coordinators, and/or Analytical staff
• Participates in HEDIS and other special projects and assignments as required.
• Educates health plan staff on aspects of quality improvement.
• Maintains current knowledge of NCQA accreditation, the US Centers for Medicare and
  Medicaid Services (CMS) and the California Department of Health Care Services (DHCS)
  requirements and health plans’ compliance related to Quality Measurement and
  Improvement, Site Review, Peer Review, and Credentialing.
• Collects, coordinates and monitors QI activities that affect other departments within the
  health plan. These include credentialing information, member complaints, appeals and
  grievances, collection and investigation of Potential Quality Issues, and Peer Review
  Committee case determinations.
• Participates on improvement teams as assigned by the Member Safety Team Manager,
  Department Director, Senior Director of Quality and Performance Improvement, or
  CMO.

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, 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.