Lead Quality Risk Management - Grievance/Appeals

Responsibilities

Come and join the RMC Family! 

We have been in the community since 1935.  Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region.  Your passion, inspiration, and talents are invaluable to us and our mission to serve others.  Our facility can provide a place for you to thrive and continue your professional development.  Quality Healthcare is our passion, improving lives is our reward.  We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care.

SUMMARY: Prepare Health Plan required reports, Action plans from audits (CAPs), medical record audits, coordinate annual HEDIS Data Collection, conduct relevant QI studies, and coordinate CPPI. Review/respond to grievances and appeals, monthly medication inventory audit, and monitor any other quality indicators. This position will help lead the daily operations of grievances and appeals process ensuring timely investigation and resolution in accordance with CMS, CDPH, and DMHC regulations and guidelines. Assist in HEDIS Data Collection and conducts Quality studies.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

HOURS: Monday - Friday, 830AM - 530PM

Qualifications

EDUCATION and/or EXPERIENCE: Associates degree from an accredited college or University preferred. Two (2) to Three (3) years of experience. Strong knowledge of Patients rights and responsibilities, familiarity with electronic health record (EHR), incident tracking based on grievances and appeals trends, skilled in coordinating case reviews, and ability to develop and monitor quality initiatives strongly preferred.

CERTIFICATION, LICENSES, AND REGISTRATIONS: Current California LVN License required and CPHQ is a plus.

ESSENTIAL FUNCTIONS:
Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job’s purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).

1. Prepare Health Plan required reports and coordinate annual audits.

2. Prepare Corrective Action Plans from audits and access issues.

3. Conduct mandatory annual medical record audits on all RMC practitioners.

4. Coordinate annual HEDIS Data Collection Project.

5. Conduct relevant Q.I. studies for both the clinic and surgery center areas and/or any other AAAHC
Regulatory preparation/requirements.

6. Perform periodic random mini- surveys at all locations to maintain AAAHC “readiness”.

7. Assist Manager, Quality, and/or Regional Director, Quality and/or Medical Director with special projects.

8. Coordinate CPPI (California Physician Performance Initiative).

9. Review/respond to health plan or individual grievances and appeals in a timely manner.

10. Assist with QRMC and MPC preparation

11. Any other responsibilities requested by Manager, Regional Director, and Medical Director .

Benefit Highlights:
• Challenging and rewarding work environment.
• Competitive compensation and paid time off.
• Excellent Medical, Dental, Vision and Life Insurance Plans.
• 401(K) with company match and discounted stock plan.

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.