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Quality Assurance Nurse, RN - Care Management (Remote)

Date: Apr 22, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 4848 


Position Summary/Position


Under the general direction of the Quality and Training Care Management Nurse Manager, the Quality Assurance Nurse, RN - CM is responsible for identifying Care Management processes that may not be meeting regulatory compliance measures. When regulatory elements are identified to be below an established bench mark the QA nurse performs a root cause analysis for all deficiencies and works with Care Management Team members to develop/implement interventions to correct identified deficiencies.

Major Functions (Duties and Responsibilities)


1. Stay current on all regulatory guidelines, i.e. DHCS, CMS, NCQA, DMHC which direct IEHP Care Management policies and processes and updates file review tools as appropriate.
2. Performs retrospective file reviews for various Care Management populations (i.e., Medicare, Cal MediConnect, Medi-Cal, Complex Care Management, California Children’s Services, Inland Regional Center Early Start) to identify significant and problematic CM quality issues and concerns. Performs root cause analysis and develops corrective action plan(s) to correct deficiencies.
3. Collaborates with Care Management Training Team to implement new processes or protocols as required by the corrective action plan to meet IEHP and regulatory standards.
4. Collaborate with Care Management Training Team to ensure accuracy of job aids and resources to identify areas of learning opportunities for Care Management staff. 
5. Assist in the development of reports and studies that will assist in the evaluation of CM activities and improve outcomes that impact CM.
6. Collaborate, research, and develop process changes that may need to be implemented to improve the CM delivery processes as indicated in report and study outcomes.
7. Collaborates with various internal IEHP departments to assist with validation of changes, updates or revisions to the medical management system.
8. In collaboration with CM QA and Training Manager and Director, update policies per protocol on an annual basis.
9. Participate in regulatory audits, audit preparedness and process meetings as required.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


One to three years experience in care management in a health care delivery system setting. Requires a minimum of one year of experience in audits and/or Quality and/or Compliance.

Preferred Experience


Experience in HMO, Managed Care preferred.

Education Qualifications


High school diploma or GED required.

Preferred Education

Professional Certification

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


Knowledge of Medi-Cal, CMS, DMHC and NCQA preferred.

Possess an understanding of and sensitivity to multi-cultural community. Prefer knowledge of Medi-Cal/Medicare managed care environment.

Skills Requirement


Possess organizational skills to maintain accurate records and documentation. Critical thinking skills, proficient in Microsoft Office applications,

Abilities Requirement


Must be able to work independently, and maintain positive relationships with internal and external contacts at all levels.

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


While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Physical Requirements


Starting Salary: $75,296.00  - $95,992.00  

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 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core 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 retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles