Quality Assurance Nurse, Rn - Behavioral Health (Remote)

Position Summary/Position

Under the direction of the Manager of Regulatory and Quality Compliance, the Quality Assurance RN- Behavioral Health, is responsible for identifying BH processes that are at risk for not meeting regulatory compliance measures. When regulatory elements are identified to be below an established bench mark the QA nurse performs a root cause analysis for all deficiencies and works with BH Team members to develop/implement interventions to correct identified deficiencies.

Major Functions (Duties and Responsibilities)

1. Stay current on all regulatory guidelines, i.e., DHCS, CMS, NCQA, DMHC which direct IEHP Behavioral Health and Care Management policies and processes and updates file review tools as appropriate.
2. Performs retrospective file reviews for various Behavioral Health and Care Management populations (i.e., BHT (Autism spectrum), Eating Disorders, complex and high-risk children), turnaround time for inpatient/outpatient BH services, Medicare, Cal MediConnect, Medi-Cal, Complex Care Management, California Children’s Services, Inland Regional Center Early Start) to identify significant and problematic BHCM quality issues and concerns. Performs root cause analysis and develops corrective action plan(s) to correct deficiencies.
3. Performs Inter-Rater Reliability (IRR) as directed for BH UM authorizations.
4. Collaborates with Behavioral Health and Care Management Team Leadership to implement new processes or protocols as required by the corrective action plan to meet IEHP and regulatory standards.
5. Collaborate with Behavioral Health and Care Management Team Leadership to ensure accuracy of job aids and resources to identify areas of learning opportunities for Behavioral Health and Care Management staff.
6. Assist in the development of reports and studies that will assist in the evaluation of Behavioral Health and Care Management activities and improve outcomes that impact the department.
7. Collaborate, research, and develop process changes that may need to be implemented to improve the Behavioral Health and Care Management delivery processes as indicated in report and study outcomes.
8. Collaborates with various internal IEHP departments to assist with validation of changes, updates, or revisions to the medical management system.
9. In collaboration with CM QA and Training Manager and Director, update policies per protocol on an annual basis.
10. Participate in regulatory audits, audit preparedness and process meetings as required (i.e., NCQA, DMHC and DHCs)

Experience Qualifications

One to three years’ experience in behavioral health care management in a health care delivery system setting. Requires a minimum of one year of experience in audits and/or Quality and/or Compliance.

Education Qualifications

Associate Degree required.

Preferred Education

Bachelor's Degree preferred.

Professional Licenses

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

Knowledge Requirement

Knowledge of Medi-Cal, CMS, DMHC and NCQA preferred.

Possess an understanding of and sensitivity to multi-cultural community. Prefer knowledge of Medi-Cal/Medicare managed care environment.

Skills Requirement

Possess organizational skills to maintain accurate records and documentation. Critical thinking skills with proficiency in Microsoft Office applications. Spanish speaking preferred, but not required.

Abilities Requirement

Must be able to work independently and maintain positive relationships with internal and external contacts at all levels.

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.