Quality Program Nurse, RN

Date: Aug 28, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5194 


Position Summary/Position


Under the direction of the Director of Quality Management, Quality Program Nurse (QPN), RN is responsible for the implementation of Quality Management policies, procedures, and activities. Quality Program Nurse, RN enforce DHCS regulatory requirements as pertaining to Facility Site Review (FSR) and Medical Record Review (MRR) criteria.

Major Functions (Duties and Responsibilities)


1. Perform initial, periodic, and verification Site Review and Medical Record Surveys for assigned Primary Care Providers. Conduct other regulatory audits as assigned.
2. Review Primary Care Provider Corrective Action Plans (CAP) submissions and monitor CAP compliance.
3. Perform focused audits as directed by IEHP Subcommittees.
4. Perform annual HEDIS data abstractions.
5. Monitor assigned PCPs for potential problem hours and document findings.
6. Review QM reports and CAP log on a weekly basis.  Responsible for Provider compliance and follow up.
7. Attendance and participation in Quality Management Committee and/or Subcommittee meetings, as needed.
8. Attend Site Review and Medical Record Survey training, as mandated by DHCS, to maintain and become a Certified Site Reviewer.
9. Attendance and participation in Quality Management Committee or Subcommittee meetings, as directed. Attendance and participation in Medical Services, and other inter-departmental staff meetings as indicated.

Experience Qualifications


Three or more years of any individual or combined experience in Quality Assurance, Utilization Management, Case Management, and/or provider liaison duties.

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


High school diploma or GED required

Professional Certification


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

If not a CSR, the candidate should be willing and able to get certified within a year of hire.

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.

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 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