Job Title: Quality of Care Coordinator Nurse
Duration: 4 Months (Potential Extension and Conversion to FTE)
Location: Remote
Work Schedule: Mon-Fri | 8-5pm EST or 8:30-5:30pm EST
PR: $35-38.00/HR
Summary:
Critical Incident management requires timely review, investigation, reporting, monitoring, provider outreach, corrective action follow-up, and case closure activities, all of which require clinical expertise and judgment.
Timely reporting and ongoing monitoring of Critical Incidents are contractual and regulatory obligations.
This position is necessary to maintain adequate clinical capacity to support compliance requirements, member safety oversight, timely regulatory reporting, and effective management of the Critical Incident and Quality of Care programs. Dedicated RN resources are required to support ongoing reporting, monitoring, investigation, and follow-up activities and ensure sustainable operational performance.
Day to Day Responsibilities:
Quality of Care/Critical Incidents Nurse
- Checking email box daily for Critical Incident referrals
- Entering referrals into the Delaware state tool
- Creating and completing assessments of the assigned member
- Communicating with the care coordination team regarding the status of the assigned member
- Updating tracker of assigned members
- And other tasks based on needs
Appeals and Grievance Nurse
- Coordinating complex appeals case
- Conducting clinical reviews
- Supporting medical necessity determinations
- Collaborating with medical doctors
- Ensuring compliance with state federal and contractual requirements
- Tracking and documenting statuses
- And other tasks based on needs
Education/Certification Required:
Licensure Required:
Years of experience required:
Disqualifiers:
Additional qualities to look for:
Skills: