Senior Insurance Quality Assurance Jobs in Riverside, CA

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

The PACE Quality Assurance (QA) Analyst will ensure top notch healthcare standards for our geriatric community. This role will investigate incidents and implement performance improvement plans as it pertains to infection control, service delivery requests (SDR), appeals, and grievance resolutions.

Schedule: Monday-Friday, 8am-5pm. This position is onsite.

Responsibilities

• Validates comprehensive data collection from relevant sources and communicates findings to stakeholders
• Conducts thorough incident report investigations, including Level II incidents, requiring in-depth root cause analysis (RCA) to identify contributing factors and prevent recurrence
• Develops and monitors a quality assessment and performance improvement plan (QAPI) under the supervision of the Medical Director, including the annual plan and its implementation
• Develops and implements the annual infection control plan and maintains an infection control program that investigates, controls, and prevents infections promptly
• Monitors, tracks, evaluates, and resolves medical and non-medical grievances, SDR’s, and appeals by participants, their families, and/or representatives
• Conducts complete chart audits to ensure participant care plans accurately reflect the services and care provided
• Identifies high-risk participants and refers them to appropriate medical leadership
• Facilitates quality assurance-related communication between contract facilities and PACE Interdisciplinary Teams
• Conducts quality assurance audits of contract facilities to ensure quality participant care
• Participates in orientation sessions and conducts onsite inspections of contracted facilities for quality assurance purposes
• Assists in developing agendas and leads Participant Advisory Committee meetings in the facilitator's absence
• Ensures staff integration into the QAPI process through continuous quality improvement education and opportunities for input
• Monitors participants' physical, mental, emotional, and social functioning; reports any changes to the licensed nurse
• Extracts quality data indicators from statistical data for quarterly submission to CMS
• Conducts participant and caregiver satisfaction surveys and reports findings on an annual basis
• Maintains confidentiality of company procedures, results, and participant/client/family information
• Practices universal precautions and adheres to infection control procedures
• Demonstrates warmth and responsiveness to all customer groups and supports the healthcare team's success
• Participates in continuing education and required staff training meetings

Qualifications

Education/Experience

• Bachelor’s degree in nursing, public health, or related field or an equivalent combination of education and experience required
• Valid CA nursing license (LVN or higher) preferred
• Nonlicensed personnel: Current Basic Life Support (BLS) certification required upon hire and must be maintained as a condition of employment. These courses must follow AHA guidelines- may be completed through approved online providers such as ProMed or other equivalent programs that meet recognized BLS standards
  • In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually
• Licensed personnel: Current Basic Life Support (BLS) certification through an American Heart Association (AHA)-approved source is required upon hire and must be maintained as a condition of employment
  • AHA-approved courses include an in-person, hands-on skills check with a certified instructor using a mannequin to demonstrate CPR and emergency response techniques
  • Online-only BLS courses without a live skills check do not meet this requirement
  • In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually
• Two years of quality assurance/performance improvement experience within a healthcare setting required
• Experience with advanced functions in Microsoft excel required

Additional Qualifications(Knowledge, Skills and Abilities)

• Excellent verbal and written communication skills with a specific focus on maintaining accurate records
• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
• Proficient in Microsoft Office applications
• Knowledgeable about and experience with basic statistical principles
• Knowledgeable about and experience with safety and infection control requirements for healthcare facilities
• Knowledgeable about and experience with quality assurance and performance improvement activities, including staff education utilizing adult learning concepts
• Ability to interact professionally and respectfully with geriatric individuals, including those with cognitive decline and/or physical frailties
• Excellent data collection and interpretation skills
• Ability to successfully manage multiple tasks simultaneously
• Ability to apply integrity, discretion, and objective problem-solving skills
• Excellent planning and organizational ability
• Ability to establish and maintain effective working relationships with participants, coworkers, medical staff, and the public
• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 10 lbs/weight
• Ability to stand for long periods of time

Neighborhood Healthcare offers a generous benefit plan that includes: Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more!

Pay range: $73,500 to $104,400 annually, depending on experience.

Compensation Disclosure: The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to the candidate’s overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.