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General Information

Work Location: Los Angeles, USA
Onsite or Remote
Flexible Hybrid
Work Schedule
Monday - Friday, 8:00am - 5:00pm PST
Posted Date
03/04/2025
Salary Range: $36.49 - 76.05 Hourly
Employment Type
2 - Staff: Career
Duration
Indefinite
Job #
22893

Primary Duties and Responsibilities

The Quality Management Nurse Specialist serves as the key resource for the investigation of member complaints, grievances, quality of care and access-related patient issues through collaboration with providers, health plans and other departments. The incumbent will conduct routine as well as ad hoc medical record and office site audits as required. As a member of the QM Team, this position assists with quality improvement studies through data collection, data input and report development. The QM Nurse Specialist will adhere to NCQA, State, Federal and other Regulatory agency standards. Additional areas of responsibility include tracking and trending complaint and grievance data to identify and report aberrant trends.

Key responsibilities include:
  • Analyze and resolve complaints/appeals: Gather and organize key information, ensuring a thorough review. Consult with Medical Directors as needed to finalize resolutions.
  • Maintain accurate records and compliance: Keep confidential documentation of complaints and grievances, respond promptly to health plan requests, and ensure all actions comply with health plan, state, and federal regulations.
  • Review medical records for denied services: Evaluate prospective, concurrent, or past medical records using clinical guidelines to determine medical appropriateness, investigating member history, clinical background, benefits, and eligibility.
  • Manage member transfer/termination requests: Track and process requests, prepare formal letters for patients and health plans documenting non-compliance or unacceptable behavior, and oversee the transfer/termination process.
  • Support quality management (QM) projects: Assist in initiatives like HEDIS/Pay for Performance, clinical studies, and access surveys by compiling data and producing reports, charts, and graphs to highlight outcomes.
  • Prepare and submit regulatory reports: Collect and submit required information for reports to regulatory agencies, health plans, and internal committees as directed by management.
  • Conduct audits and ensure compliance: Schedule and perform medical record and facility site audits based on NCQA, CMS, DHS, and health plan standards. Develop corrective action plans, follow up on issues, and generate reports.
  • Oversee credentialing and re-credentialing processes: Manage QM activities, ensuring required documentation (site reviews, medical record audits, study participation, and grievance outcomes) is submitted promptly to the Credentialing Oversight Coordinator/Provider Relations unit.
  • Assist with health plan audits: Help prepare for audits by ensuring all documentation and processes meet requirements, working with management to implement necessary improvements.

Salary Range: $36.49 - $76.05 Hourly

Job Qualifications

  • Current LVN or RN licensure in the state of California required. If providing RN licensure, a BSN is required.
  • Minimum five years of Managed Care experience required
  • Minimum three years of experience in Utilization Management or Quality Management required
  • Ability to operate a wide variety of office equipment, including computers, printers, copy machines, facsimile receiver/transmitter, scanners and mailing equipment
  • Proficient computer skills including working knowledge of Microsoft Excel and Word
  • Ability to multi-task, work with frequent interruptions and meet deadlines
  • Must be detailed oriented, attentive, organized, and able to follow directions
  • Ability to communicate thoughts and information clearly and succinctly in writing as well as verbally
  • Ability to lift up to 25 pounds

As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.