Utilization Review Jobs in Merced, CA (NOW HIRING)

Under the supervision of the Director of Center Operations RN, develops, organizes and monitors a Quality Assessment and Performance Improvement Plan (QAPI) for the PACE program. The Quality Manager RN is responsible for developing the QAPI annual plan, and guiding the implementation of the plan. Ensuring that data is collected from all appropriate sources; and the data is examined and the results are shared with all stakeholders. Oversees the process to evaluate and resolve medical and non-medical grievances and appeals by participants, their family members, or representatives.  Manages the Utilization team and quality specialists.  Manages utilization review and management for all acute, post-acute, and outpatient services as well as performing the identification, analysis and resolution of resource utilization outliers consistent with established protocols, policies and procedures.

Schedule is Monday – Friday, working from 8:00am – 5:00pm.

This position will work at our PACE Centers in Merced, Modesto, and Stockton (once operational).

Compensation:

$114,982.40 - $134,451.20 Salary

Employee Benefits:

• Health, Dental, and Vision Insurance
• Life, Accidental Death & Dismemberment (AD&D), and Long Term Disability (LTD) Insurance
• Retirement Savings: 403(b) plan with an employer match, Roth 403(b) option, plus a 401(a) retirement benefit after one year of service.
• Flexible Savings Account
• Work/life balance: 13 days of vacation, 11 days honored as Paid Holiday Off – 2 are half days (New Years Day and Christmas Eve Day). 

Duties and Responsibilities

• Develops and guides the implementation of the annual QAPI Plan.
• Reports data and information to QA Committee, Executive Team, and PACE Board of Directors.
• Ensures staff integration into the QAPI process through Continuous Quality Improvement education and developing opportunities for input.
• Analyses of risk management data, and Quality Assessment Performance Improvement activities data with the objective of identifying and controlling loss to protect the assets of the organization.
• Reports data and information in the manner and at the time intervals specified by CMS and the State agency pertaining to participant care activities and outcomes.
• Facilitates quality assurance-related communication between contract facilities and PACE Interdisciplinary Teams.
• Participates in orientation with staff and contract facilities to ensure effective coordination of participant care, as needed provides scheduled onsite inspection of contracted facilities to ensure quality care is provided and compliance with State and CMS regulations.
• Facilitates the Quality Assurance Performance Improvement process for various services areas within PACE.
• Oversees the process to evaluate, and resolve medical and non-medical grievances and appeals by participants, and/or their representatives, ensures information is reviewed for incorporating issues in development of Quality improvement initiatives and annual QAPI plan.
• Develops and guides the implementation of the annual Infection Control Plan.
• Establish, maintain, and implement an infection control program that investigates, controls, and prevents infections in a timely manner.
• Analyze patterns of infected participants, changes in prevalent organisms and increases in the rate of infection.
• Obtain surveillance data for the prevention and control of additional cases, maintain a record of infections and report outcomes to state and CMS agencies as required.
• Conducts annual satisfaction surveys of the participants and caregivers of PACE, and reports findings.
• Attends the Participant Advisory Committee, assists in development of agendas and leads meeting in facilitator’s absence.
• Works with the contracted credentialing liaison and Medical Director to ensure credentialing files are completed and approved.
• Manages concurrent and retrospective utilization management reviews and functions; collect, analyze, and report outcomes to internal and external stakeholders.
• Identify high-risk patients via inpatient rounds, provider referral patterns, utilization management referrals, and disease registry reporting mechanisms, and refer to appropriate PACE site medical leadership.
• Develop and implement written policies, procedures and standards of conduct to ensure PACE commitment to detect, correct and prevent FWA.
• Develop and implement procedures for effective internal monitoring and auditing of FWA, ensuring prompt responses to FWA and a well as corrective action.
• Responsible for the training and education related to detection, correction, prevention and corrective action of FWA to PACE employees, subcontractors, and any other appropriate entities.
• Responsible for training of direct patient care staff, assessment and tracking of competencies and continued evaluation.
• Performs contract facility quality assurance audits to ensure quality participant care.
• Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
• Observe each participant for any change in physical, mental, emotional and social functioning and shall report such changes to the licensed nurse.
• Maintains the confidentiality of all company procedures, results, and information about participants, clients or families.
• Displays a willingness and ability to be responsive in a warm and caring manner to all customer groups and support the success of the entire healthcare team.
• Participates in continuing education classes and any required staff and training meetings.
• Ensures that the job responsibilities, authorities and accountability of all direct reports are defined and understood.
• Practices universal precautions and follows all appropriate infection control procedures.
• Other projects and duties as assigned.

Physical Demands

• Requires standing, walking, occasional pushing, pulling, and lifting.
• Ability to lift up to 30 pounds. Moving, lifting or transferring patients may involve lifting or pushing greater than 30 pounds, should be done with assistance as appropriate. 
• Requires manual and finger dexterity and eye-hand coordination.
• Visual, Hearing and Communication Requirements – Requires corrected vision and hearing to normal range.
• Must be able to document care provided in participants’ service records.
• Must be able to communicate verbally with participants their treatment plan, team members and participants caregivers.
• Must have vision with or without lenses that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.
• Subject to participants that may have the potential for verbal or physical aggression. Must be able to communicate verbally with all staff, caregivers, participants, and community at large.
• Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.

Work Environment

• The noise level is usually quiet to moderate, but may at times be noisy and crowded.
• Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment.
• Subject to unpleasant odors.

Education/Experience Requirements

Minimum Qualifications

• Valid CA Driver’s License, acceptable driving record, and vehicle insurance.
• Ability to lead and supervise effectively.
• Creative, detailed-oriented and organized.
• Excellent written and verbal communication skills with specific ability to maintain accurate records.
• Ability to facilitate effective meetings.
• Works well under pressure
• Excellent customer service skills.
• Must have integrity, practice discretion and practice objective problem solving.
• Data collection skills and knowledge of basic statistical principles.
• Skilled in establishing and maintaining effective working relationships with participants, coworkers, medical staff, and the public.
• Skilled in identifying and recommending problem resolution.
• Knowledge of safety and infection control requirements for healthcare facilities.
• Demonstrated experience in quality assurance and performance improvement activities and in the development and implementation of staff education with application of adult learning concepts.
• Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
• Maintains professional affiliations and any required certifications.

Education/Experience

• Graduate of an accredited school of professional nursing.
• Current unencumbered CA Registered Nurse (RN) License.
• Current BLS CPR Card certified by American Heart Association.
• Minimum three (3) years RN experience with at least two (2) years working with the frail or elderly population
• Bachelors of Science in Nursing preferred, or four (4) years of work related experience in lieu of degree.
• Minimum of four (4) years of demonstrated experience in quality assurance and performance improvement activities in a health related work environment.