You Make Us Grow. You Make Us Sharp.

Hours:

Shift Start Time:

8 AM

Shift End Time:

5 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

No Weekends

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$36.830 - $47.530 - $53.230

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do
Under the direction of the UM Supervisor, utilizes critical thinking and clinical expertise in various quality improvement activities. Supports the Sharp Community Medical Group Quality Management and Utilization Management Programs, through quality of care reviews, complaint and dismissal investigations, clinical appeal coordination, data collection and measurement, analysis and interpretation, and evaluation and reporting of key performance measures and improvement activities. Additionally, the Quality Analyst LVN acts upon opportunities of improvement and maintains the department processes in compliance with State and Federal Standards.

Required Qualifications

• 2 Years Clinical experience in the patient care setting (experience in both acute and ambulatory care preferred)
• California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED

Preferred Qualifications

• Bachelor's Degree Related field
• Experience in both acute and ambulatory care
• 1 Year Utilization Management/Case Management/Quality Management experience

Essential Functions

• Analyzes and prepares data
  Provides documentation and statistics as requested by Supervisor or Manager. Utilizes departmental databases and computer software programs, i.e. IDX Customer Service Module, Microsoft Word/Excel/Access/Power Point, and other programs to collect and analyze data, produce accurate reports, identify and report trends.
  Prepares documentation for review and discussion at the SCMG UMC/QOC Committees as requested by Supervisor or Manger. Such documentation could include policies and procedures, quality activities, peer review and re-credentialing reports.
  Provides assistance with goal setting, reporting and evaluation for applicable quality activities (i.e.: ICE Annual work plan, health plan reporting).
• Clinical appeals
  Facilitates and coordinates clinical appeals processes to meet SCMG, health plan, and regulatory requirements in a timely, efficient manner utilizing clinical knowledge and strong communication and problem solving skills.
  Collaborates with the provider offices, the health plans, other SCMG departments/staff and Medical Directors.
  Reviews, investigates, and responds to clinical appeal inquiries received from contracted health plans in strict accordance with the health plan appeals policies and timeliness standards.
  Maintains accurate, timely documentation of clinical appeals inquiries and accesses computer systems, i.e. IDX Referral Module or Customer Service Module, to research and document appeals related activities.
  Serves as a liaison/resource for other HSM departments, and Customer Service department on appeals issues.
  Assists in identifying learning needs and the ongoing education of SCMG staff, providers, physicians and their office staff.
  Utilizes systems to inform/monitor staff compliance with regulatory and accreditation standards.
  Processes appeals, overturn timely and accurately according to healthplan requirements and department guidelines.
• Compliance
  Maintains the Quality and Utilization Management policies and procedures by updating information according to department guidelines and regulatory and compliance requirements.
  Reviews compliance with health plan requirements at least annually in preparation for upcoming Utilization Management audits and coordinates changes in internal processes to ensure compliance. Acts upon health plan audit results in conjunction with Quality Supervisor or Department Manager.
  Maintains the UM SharePoint site for the UM Department, adding new content/areas and creating back-ups per department guidelines.
  Performs other duties as requested. These may include, but are not limited to: workgroups, survey, audits, and back-up support for others.
• Member dismissals
  Receives and coordinates requests for PCP transfers and member dismissals through collaboration with the provider offices, the health plans, other SCMG departments, and the Health Services Management Staff in an effective and efficient manner.
  Maintains accurate and confidential documentation related to member counseling and dismissals and responds appropriately and timely to SCMG staff, practitioner and health plan requests and inquiries.
  Coordinates communication with SCMG practitioner offices and SCMG Case Managers to prepare correspondence to members, health plans, and practitioners.
  Utilizes computer databases and spreadsheets to track and trend member dismissals in order to identify and report adverse or aberrant trends.
• Professionalism
  Demonstrates courteous, professional, and cooperative demeanor toward coworkers, patients, physician, and health plan contacts.
  Demonstrates dependability as evidenced by punctuality, timeliness of reports, and timely notification to supervisor of deviation from schedule hours.
  Performs other duties or such as special projects when assigned and provides back up for other department staff as deemed necessary by the Manager or Supervisor.
  Accepts work readily and completes work within specified timeframes. Keeps Supervisor and co-workers advised of progress.
• Quality
  Quality Reviews - Quality Variance Events and Grievances
  
  Receives and investigates quality variance events, member grievances or other quality related issues through collaboration with the provider offices, the health plans, other SCMG Departments, and the Health Services Management Staff.
  Maintains accurate and confidential documentation related to quality variance events, member grievances, or other quality related issues and responds appropriately and timely to health plan requests and inquiries.
  Utilizes computer databases and spreadsheets to track and trend data from quality variance events, grievances, or other quality related issues in order to identify and report adverse or aberrant trends.
  Accesses existing computer systems, i.e. IDX Referral Module, Customer Service Module, and OnBase, to research and document quality variance events, grievances, or other quality related issues.
• Quality monitoring
  
  Utilizing Utilization Management reports, performs internal audits for SCMG and Partner organization on the various UM activities as assigned by Department Supervisor or Manager.
  Participates in ICE and other accreditation organizations and acts upon information provided to ensure SCMG's compliance.
  Keeps current knowledge and understanding of applicable health plans, accreditation, and regulatory requirements related to managed care and assigned job responsibilities.
  Coordinates site audits for quality issues/grievances to support compliance with regulatory requirements and credentialing/recredentialing activity.
  Actively participates in process improvement activities in the department and assigned by the Quality Supervisor or Department Manager.
  Seeks direction from Supervisor or Department Manager for instances that do not fall under a defined process.

Knowledge, Skills, and Abilities

• Strong knowledge of the current standards of medical practice and strong clinical acumen required.
• Patient care evaluation skills and the strong ability to communicate, both orally and in writing, with all levels of management, medical staff and patients.
• Thorough working knowledge of Word, Excel, Powerpoint and Access.
• Working knowledge of IDX Referral and Customer Service Modules helpful.
• Excellent organizational and time management skills, and the ability to handle multiple conflicting priorities simultaneously a must.
• Strong ability to prioritize.
• Ability to contribute creative and innovative ideas to help achieve the goals and objectives of the SCMG Utilization and Quality Management Programs and Work Plans.
• Ability to work independently with minimal supervision when necessary.
• Ability to present information succinctly and accurately.
• Strong ability to analyze information or data to identify adverse trends or problems, offer suggestions for corrective actions and perform ongoing monitoring.
• Expertise in Lean Six Sigma or Continuous Quality Improvement (CQI) helpful.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians; Bachelor's Degree