Clinical Quality Team Lead
Registered nurse (RN) or
Licensed Counselor of Social Work (LCSW)
Ensures compliance with contract requirements for clinical quality management (CQM) to ensure quality care. Identifies and evaluates potential quality issues and prepares summaries for further review and analysis. Supports activities of peer review and quality and safety committees. Reviews discharge summaries and consultation reports for compliance with clinical quality and contract requirements.
Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state
3 years clinical experience (medical/surgical or behavioral health)
Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ)
1 or more years team lead or supervisory experience
1 year experience in Quality Management
1 year experience with data analysis and reporting
Experience with InterQual or similar criteria sets General knowledge of Medicare, or government health care programs
Identifies Potential Quality Issues (PQIs) by performing a timely review of medical documentation. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.
Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans.
Reviews Practice Pattern Analyses to assist with identifying physician practice patterns for confirmed severity cases.
Collaborates for data collection, reporting, and analysis of quality issues and contract compliance.
Participates on safety and quality committees and peer review committees.
Reviews Potential Quality Issues with Chief Medical Officer when appropriate.
Provides support for the Clinical Quality committee meetings through case summary and report preparation.
Provides supervisory/team lead support for Complex Authorization Specialists.
Excellent Benefits and Matching 401K
This is a Direct Hire opportunity