Quality Improvement Nurse, RN (Remote)

Date: Jan 9, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5710 


Position Summary/Position


Under the general direction of the Quality Management Nurse Manager, the Quality Improvement Nurse, RN is responsible for investigating cases, reviewing escalated issues, and/or providers referred to the Quality Management (QM) department.

Major Functions (Duties and Responsibilities)


1. Responsible for investigating, completing case summaries, and making recommendations for any Potential Quality of Care Incidents (PQI) referred to the QM department. 
2. Responsible for 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. Responsible for reviewing 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. Responsible for reviewing 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. Responsible for data entry into database systems, maintaining updated documentation and other tracking mechanisms for all cases.
6. Responsible for reviewing and executing ad hoc requests and/or focused audits, as needed.
7. Responsible for escalating issues of non-compliance to the Quality Systems Management team.
8. Responsible for maintaining working knowledge of regulatory requirements as they relate to QM operations and protocols. 
9. Attend Site Review and Medical Record Survey training, as mandated by DHCS, to become a Certified Site Reviewer, as needed.
10. Demonstrate a commitment to incorporate LEAN principles into daily work.

Experience Qualifications


Three or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or provider liaison duties. Three or more years experience in an acute care setting.

Preferred Experience


Experience in quality assurance, utilization management, case management, and/or provider liaison duties, preferably in an HMO or Managed Care setting.

Education Qualifications


Bachelor's Degree in nursing, health care, business administration, or related field from an accredited institution required.

Professional Certification


Possession of an active, unrestricted, and unencumbered Certified Site Reviewer Certificate issued from DHS or participating Medi-Cal Managed Health Plan Provider, preferred.

If not certified, will be required to become certified within year of hire date.

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.

Skills Requirement


Microcomputer applications: spreadsheet, database, and word processing. Excellent written and verbal communication skills.

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.

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.


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