Quality of care Investigative Nurse

This position reports to the client – Quality Management Unit and conducts quality-of-care investigations pursuant to the contract between the client. This position participates in investigations of member-centric and systemic quality-of-care concerns to ensure member health and well-being.
Conducts timely, thorough, member centric, and systemic investigations of all division member quality-of-care issues and implements vendor-specific corrective action plans, utilizing a standardized process. Makes appropriate referrals to oversight and
regulatory agencies. Participates in Care Concerns, Care Needed today, and member issues as assigned. Maintains all necessary documentation to support case work. Request appropriate documentation for quality-of-care investigations and ensure the maintenance of comprehensive case records to support allegation review and substantiation levels. As a result of the QOC Investigation, issue remediation or a Corrective Action Plan to the vendor, and ensure all applicable investigative information and documents are uploaded within the client QMS Portal. Appropriately elevates cases and/or trend concerns to the QOC supervisor.

Skills:
Critical thinking
Technological skills, including the use of databases, Microsoft Office products, email, and electronic referral and verification sources.
Producing professional technical reports and letters.
Research and analysis.
Oral and written communication skills.
Personal planning, organization, and time management.
Medical chart review.
Nursing Process, including assessment, monitoring, and evaluation.
Decision-making skills.
Critically analyze problems and develop effective plans for corrective action.

Required Education:

Should have 6 months to a year of risk management, quality assurance nurse or auditing experience
This position requires that the successful candidate possess and maintain an active license to practice as a Registered Nurse (RN) in the state of AZ.


Notes:
The first day would need to be in person to obtain equipment and complete necessary security training to be able to access systems. Afterwards, the remaining onboarding and training will be remote.