Job Description

Job Requisition ID: 10298  

Position Summary/Position

Under the direction of the Quality Management Nurse Manager, the Nurse Educator is responsible for the implementation of a variety of activities supporting Quality Management (QM) policies, procedures, and projects, as required by regulatory guidelines and by quality improvement initiatives. Provides clinical and quality improvement trainings to network Providers in the provider office setting. Is responsible for staying up to date on all quality measure requirements in support of IEHP's quality initiatives, including expertise in HEDIS (Healthcare Effectiveness Data and Information Set) and CAHPS (Consumer Assessment of Healthcare Providers and Systems) measures.

Major Functions (Duties and Responsibilities)

1. Provide on-site clinical and regulatory trainings to the Provider network. Coordinate trainings with other departments such as Provider Services, Contracting, Medical Management, etc. to ensure comprehensive and effective delivery.
2. Perform Facility Site Audit and Medical Record Audit trainings for Primary Care Providers in preparation for regulatory audits.
3. Develop and facilitate trainings for targeted quality initiatives including HEDIS measures, Access standards, Referral management, Medical Record documentation, etc.
4. Responsible for participating in the development, research, and implementation of HEDIS improvement activities, as directed.
5. Responsible for understanding current HEDIS technical specifications with the ability to interpret changes for clarifications accurately, as assigned.
6. Responsible for maintaining working knowledge of regulatory requirements as they relate to QM operations and protocols.
7. Participate in medical record abstraction activities, including accuracy validations (over-reads) for HEDIS reporting that support audit requirements, as assigned.
8. Perform Quality studies in coordination with the Quality Systems Department, as needed.
9. Perform focused trainings/audits in targeted clinical areas, when indicated.
10. Attend Site Review and Medical Record Survey training, as mandated by DHCS, to become a Certified Site Reviewer, as needed.
11. Responsible for validating, reviewing, and making recommendations for CMS ancillary audits.
12. Responsible for completing DHCS and other regulatory audits as assigned.
13. Attendance and participation in Quality Management Committee or Subcommittee meetings, as directed.
14. Demonstrate a commitment to incorporate LEAN principles into daily work.

Experience Qualifications

Three (3) or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or provider liaison duties. Two (2) or more years experience working in a clinical 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

Associates in Nursing or Bachelor of Science in Nursing from an accredited institution required.

Preferred Education

Bachelor of Science in Nursing from an accredited institution preferred.

Professional Certification

Possession of an active, unrestricted, and unencumbered Certified Site Reviewer Certificate issued from DHCS or participating Medi-Cal Managed Health Plan Provider is recommended. If not a CSR, the candidate should be willing and able to get certified within six (6) months of hire.

Professional Licenses

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

Drivers License Required

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

Skills Requirement

Excellent written and verbal communication skills that adapt to targeted audience.

Abilities Requirement

Ability to demonstrate critical thinking, strong problem solving capability, and strong attention to detail. 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.

Work Model Location

Telecommute

A reasonable salary expectation is between $79,809.60 and $101,774.40, based upon experience and internal equity.

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, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 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 stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.

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