Provider Quality Review Nurse, RN (Remote)

Date: Nov 4, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8160 


Position Summary/Position


At Inland Empire Health Plan (IEHP), we believe the highest quality of care should be delivered to all in the Inland Empire.  We are thinking beyond the way Quality is viewed today – we believe it should be holistic and transformative.  IEHP’s provider incentive programs serve an important role in achieving IEHP’s quality goals.

Reporting to the Manager of Provider Quality Oversight, the Provider Quality Review Nurse, RN is responsible for:
- Receive and research all PQI and QR cases as assigned, provide a summary and recommendations to the Medical Director of case assignments.
- Effectuate all action items as determined by the Medical Director to resolution of case assignments. 
- Reviewing escalated issues
- Discussing, and reviewing cases with Medical Directors referred to the Quality Management (QM) department. 
- Investigation of cases includes, but not limited to, the documentation of case summaries, follow up actions, outreach efforts, and communications in the QM database.

Major Functions (Duties and Responsibilities)


1. Investigate and complete case summaries and make recommendations for any Potential Quality of Care Incidents (PQI) referred to the QM department. 
2. Maintain direct communication with IEHP departments, external facilities including hospitals, Skilled Nursing Facilities, and/or Providers to ensure all PQI issues are thoroughly investigated, and care is coordinated in a timely manner, as needed.
3. Review requested medical records to ensure complete case documentation is received from all practitioners, providers, and entities/agencies to ensure thorough investigation of the issue.
4. Review case findings and recommendations with Medical Director. Issue Corrective Action Plans (CAP), review CAP responses, draft Opportunity for Improvement letters, and coordinate other interventions as needed to ensure all issues were addressed and future occurrences of the same issue are mitigated.
5. Complete data entry into database systems, maintain updated documentation and other tracking mechanisms for all cases.
6. Review and execute ad hoc requests, quality reviews, and/or focused audits, as needed.
7. Escalate issues of non-compliance to the Quality Systems Management team.
8. Maintain working knowledge of regulatory requirements as they relate to QM operations and protocols. 
9. Complete other tasks and assignments based on department and business needs.
10. Demonstrate a commitment to incorporate LEAN principles into daily work.

Experience Qualifications


Three (3) or more years of any individual or combined healthcare experience in quality assurance, quality management, quality improvement, utilization management, discharge planning, and/or case management. Three (3) or more years of work experience in a managed care, hospital, provider practice, or other comparable healthcare experience.

Preferred Experience


Experience preferably in a quality/performance improvement setting.

Education Qualifications


Bachelor's degree in Nursing from an accredited institution required.

Significant experience may be considered in lieu of degree: In lieu of a degree, a minimum of seven (7) years of relevant work experience is required.

Preferred Education

Professional Certification


Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Clinical certification in area specialty) preferred.

Professional Licenses


Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Excellent understanding of performance improvement, quality assurance, and utilization management. Knowledgeable in clinical analysis of health records, assessing or evaluating quality, and identifying problems or issues with care delivery.

Skills Requirement


Microcomputer applications: spreadsheet, database, and word processing. Excellent written and verbal communication skills. Excellent coordination skills. Ability to communicate findings and form recommendations based on clinical case reviews. 

Abilities Requirement


Ability to demonstrate critical thinking, strong problem-solving capability. Strong attention to detail. Ability to prioritize work to ensure adherence to project deadlines. Ability to effectively escalate issues as identified, following established protocols. Positive attitude and ability to work in a team setting. Self-direction and ability to work with minimal supervision.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire.

Position is eligible for telecommuting/remote work model upon completing the necessary steps and receiving HR approval. The incumbent approved to telecommute may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs determined by IEHP leadership.


Starting Salary: $79,809.60  - $101,774.40  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 7,000 and a team of more than 2,500 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles