RN Clinical Reviewer Job in Woodland Hills

Location: Woodland Hills
Posted on: November 4, 2024

Job Description:

Our large national healthcare client has a job opening for a RN Clinical Reviewer in Woodland Hills, CA!
 
Clinical Quality Review (CQR) Department investigates and reviews potential quality of care issues (PQIs) arising from member grievances and internal referrals. This refers to quality of care issues which have the potential to result in harm or actually resulted in harm to the member including serious or life threatening issues. CQR identifies opportunities of improvement when contracted providers exhibit patterns of substandard practice or practices which are not within the framework of accepted community practices.
 
Responsibilities:
• Analyzes quality issues from both internal and external sources. Summarizes pertinent medical records and refers case to Quality Medical Director for severity level review based on CQR protocols. Review could include escalation to Peer Review Committee or Credentialing Committee
• Prepares corrective action requests for cases in which it is deemed necessary for the provider to institute a change in practice. Corresponds with physicians regarding corrective actions follow-up
•Participates in regular Clinical Review Meetings with Medical Director
• Participates in regulatory audits
• Participates in special projects as assigned
 
Job Required Education/Clinical/Quality Management Experience:
• Current CA RN License. Undergraduate degree. Advanced Degree preferred and/or combination of equivalent experience training and education.
• Extensive clinical experience in nursing required.
• Managed care experience required i.e. broad knowledge of current concepts, practices and procedures within health care field.
 
•QM experience and CPHQ certification preferred
 
Other Desired Skills:
• Strong investigative , problem solving and clinical documentation/assessment skills
•Solid computer (Word, Excel, etc) and typing competencies
•Strong verbal and written communication skills.
• Knowledge of basic regulatory requirements and substantial knowledge of quality principles
•Ability to mentor and train new reviewers.
 
 
To be considered for the RN Clinical Reviewer position, you must apply online and submit your resume to Modis.com. We are actively monitoring all applications.
 
Thank you for partnering with Modis!
 

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