Quality Compliance Nurse

Company: Health Net
Location: El Centro
Posted on: April 16, 2024

Job Description:

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: The Quality Compliance Nurse-CA Only conducts on-site visits, follow-up in-services and participates in corrective action plan completion with individual Primary Care Physicians (PCP) and Participating Provider Groups (PPG) Facility Site and Medical Record Review requirements.

• Demonstrates regular, reliable and predictable attendance.
  
  • Conducts facility site and medical record reviews with individual PCPs and PPG for Facility Site and Medical Record Review compliance.
    
    • Coordinates, schedules and completes all site reviews and medical record reviews using Health Care Facility Site and Medical Record Review tool.
      
      • Completes site reviews and medical record reviews using the Facility Site and Medical Record Review tool.
        
        • Completes Facility Site and Medical Record Review site tools, containing a confirmation signing by the Primary Care Physician (PCP), and a Corrective Action Plan (AP) report, which includes recommendation for corrections of deficiencies found at the time of the review within agreed upon timeframe.
          
          • Participates in inter-rater reliability (IRR) audits annually and maintains Reviewer Certification status.
            
            • Coordinates and conducts both individual and group in-services for PCPs and PPG's, providing detailed instruction and assistance for implementation of mechanisms to improve compliance with DHS requirements.
              
              • Addresses and documents Facility Site and Medical Record Review related provider's issues and stated by individual PCPs and PPGs.
                
                • Communicates managed care concepts, Health Net's philosophy, policies to PPGs, individual PCPs, PCP staff, fellow employees and the health care community.
                  
                  • Provides professional courtesy, customer friendly services to contracted practitioners and office staff.
                  • Performs other duties as assigned
                    
                    • Complies with all policies and standardsEducation/Experience: Bachelor's degree in health related field (Hospital Administration, Health Science, etc.) or strong related experience preferred
                      
                      • Communications or business experience in a health related environment
                      • Two to three years experience in a managed care environment coordinating programs/seminars for providers
                      • 1 - 3 Years Clinical Experience preferred
                        License/Certification:
                        
                        • RN California License with previous regulatory audit experience preferred
                        • Facility Site Reviewer Certification
                          Government Security/Clearance/Citizenship Requirements:Pay Range: $32.41 - $58.31 per hourCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Keywords: Health Net, Palm Desert , Quality Compliance Nurse, Other , El Centro, California