Commercial Roofing Service Sales

Department(s): Quality Improvement

Reports to: Manager, Quality Improvement (PQI)

FLSA status: Non - Exempt

Salary Grade: M - $85,000 - $141,086

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Wednesday ** , Octo ber 18, 2023 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. **

About CalOptima Health

CalOptima Health is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima Health.

About the Position

The QI Nurse Specialist-Potential Quality Issue (PQI) is responsible for participating in handling the organization's quality of care grievance review process including investigation of all quality reviews for potential quality of care concerns. The incumbent will be involved with the collection of appropriate data and closing cases by preparing and submitting the cases to the appropriate physician reviewer and committees for closure. The incumbent ensures grievances/complaints and PQIs are processed in accordance with regulations, compliance standards and policies and procedures.

Duties & Responsibilities

• Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
• Ensures integrity of departmental database by thorough, timely and accurate entry of cases.
• Participates in departmental meetings, trainings and audits as requested.
• Assists with the intake of cases in the department.
• Reviews productivity and timeliness for quality of care grievances and PQIs through the use of reports.
• Performs investigations of unusual occurrences/events from sources (providers, staff, hotline, etc.) and assesses the criticality of events.
• Maintains and supports a culture of compliance, ethics and integrity.
• Maintains knowledge of policies and procedures and performs in accordance with applicable regulatory requirements, external laws and accreditation standards as they relate to business and clinical risk management.
• Performs clinical assessments of member complaints and intervenes as needed for urgent clinical issues.
• Develops a thorough clinical review and written report for cases referred for PQI investigations.
• Completes other projects and duties as assigned.

Experience & Education

• Bachelor’s degree in Nursing or Health Services required.
• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.
• 5 years of experience in patient care required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications

• Certification in Case Management (CCM) or Certified Professional in Healthcare Quality (CPHQ).
• 2 years of experience in a managed care setting.
• Project management skills.

Physical Demands and Work Environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of the job, employee may need to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Employee must be able to communicate, particularly for regular phone use.
• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.

About our Benefits & Wellness options

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

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CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

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If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

Required Skills

Required Experience