- PURPOSE:The Quality of Care Nurse will effectively identify, prioritize and respond to high level grievances, complaints and complaint appeals from the member or member’s authorized representative for the Commercial or Medicare Advantage lines of business.
- The incumbent reviews and interprets the grievance or complaint, medical and dental records, narrative notes, in-patient/office policies and all documentation submitted or collected by the plan pertinent to the issue.
- The incumbent will also understand the merits of legal and accreditation actions.
- ESSENTIAL FUNCTIONS:Reviews all member grievances or complaints and complaint appeals concerning the quality of care provided by facilities or practitioners.
- Contacts members, providers, or other parties involved, as appropriate, verbally and in writing to obtain additional information regarding the complaint.
- Reviews medical and dental claims information and records, and member and provider correspondence to conduct patient care investigations and renders an investigative finding.
- Provides detailed written and/or verbal responses to members, providers, and authorized representatives upon completion of a thorough investigation.
- Responds to follow up questions or concerns with members, providers, and other parties involved in the investigation, as appropriate.
- Prepares training materials and serves as the professional resource for all quality of care complaints and quality of care appeal complaints.
- Conducts or participates in nursing research as appropriate.
- Completes medical research by defining and interpreting medical language, defining and interpreting medical procedures and medical/hospital office policies.
- Assists with the preparation of regulatory reports by detailing and summarizing the merits of legal or accreditation actions.
- QUALIFICATIONS:Education Level:Licenses/Certifications:RN – Registered Nurse – State Licensure And/or Compact State Licensure Practice in MD, DC, VA, WV.Experience: 5 years Clinical experience in direct health care or health insurance payor setting working with quality reporting, or analytics.
- Working knowledge of NCQA standards.
- Bachelor’s degree in Nursing.
- Behavioral Health Experience.
- Knowledge, Skills and Abilities (KSAs)Demonstrates excellent written and oral communication skills along with effective presentation skills.
- Able to provide verbal and written feedback for improvement.
- Must understand the appropriate mode of communication based on the subject matter.
- Computer proficiency and technical aptitude with the ability to utilize MS Office (Excel, Word and Outlook) and web based technology.
- Ability to exercise sound judgment in making critical decisions.
- Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
- Knowledge of patient rights and laws relative to those rights, such as HIPAAAbility to effectively communicate and provide positive customer service to every internal and external customerProficient in standard medical practices and insurance benefit structures with the ability to use them in varied siturationMust be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
- Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
- Department Department: DC Medicaid – Enrollment ServiceEqual Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.
- It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
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