QI Nurse Specialist (Model of Care Review) (15113-15112-103114): Details: The QI Nurse Specialist for Model of Care review is responsible for detailed and intensive investigation into cases referred to an Interdisciplinary Care Team (ICT). The nurse receives and reviews ICT summaries and Individualized Care Plans (ICP) to ensure compliance with Centers for Medicare and Medicaid Services (CMS) and Model of Care (MOC) requirements. The position works as a resource for OneCare members, delegated plan case managers, personal care coordinators (PCCs) and community partners to address medical, behavior, and psychosocial concerns. In conjunction with other team members, develops and makes recommendations for a comprehensive individualized care plan at all levels of care. Position Responsibilities Work in collaboration with an interdisciplinary team to identify and work toward timely resolution of issues that meet the member’s needs through evaluation and support of OneCare members in all care settings. Work collaboratively with the Physician Medical Groups (PMGs) to provide feedback for ICT participation and ICP development using member Health Risk Assessment (HRA) data. Produce productivity reports reflecting numbers of returned ICP files reviewed within a given period of time. Assist, as requested, to collect and analyze data from initial/annual/updated health risk assessments, stratification tools, outcome measures and internal/external reports in order to identify trends, individual issues, problems, and resources that are most appropriate to meet member’s needs. Develop and maintain a network of current community resources and services where members can be referred to for assistance. Assist with the establishment of measurable standards and reporting for monitoring the OneCare team’s internal processes and make recommendations for areas of improvement. Perform regular review of cases and events to identify patterns/trends and to ensure the department’s compliance with CMS, DHCS and NCQA standards. Attend Joint Operational Meetings (JOMs) with PMGs and OneCare business workgroups as requested. Serve as a liaison and resource between OneCare and the PMGs (including Customer Service, Utilization Management and Case Management), and Orange County Social Services. Develop and maintain a good working relationship with all areas. Collect and analyze data to monitor member satisfaction and compliance with delegation oversight requirements. Collect and analyze data to identify clinical opportunities for improvement. Other projects and duties as assigned. dlvr.it/7PYVhy
Posted on: Mon, 03 Nov 2014 11:46:17 +0000
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