Trainer/Quality Registered Nurse

Summary

Responsibilities include providing clinical and educational support assessments, analysis, coordination of the quality management program, assisting in the divisional accreditation process, and conducting/assisting with internal and external audits.

ESSENTIAL DUTIES AND RESPONSIBILITIES (Other duties may be assigned)

• Responsible for educating staff in managed care as it relates to department programs, processes, and systems.
• Conduct quality reviews on cases for the UM department.
• Develops, implements and updates training manuals reflecting new approaches to training, departmental and/or system process changes and with medical policy updates as needed.
• Oversee and mentor new employees during the initial training program.
• Oversee and monitor quality/training tasks quality/training analysts.
• Work closely with the leadership team and subject matter experts external and internal to assess the learning environment and determine relevant resources for training. 
• Educate staff and external provider facilities in the clinical policies criteria and procedures of application of medical policy and IQ as well as an overview of the department, general functions, responsibilities, and department relationships with other departments.
• Prepare all training materials and develop training packages with related materials assigned by leadership.
• Participate in development, testing and implementation of new programs and systems as assigned.
• Share performance information with operations and training management to determine next steps. 
• Coordinate administrative activities with the training supervisor and operations management, including class evaluations, updating files, class registration, scheduling classes, new hire system/software access, personnel information, and attendance management.
• Coordinate and perform internal and external audits as required.
• Registered Nurse with current unrestricted Michigan Registered Nurse license required.
• Effective analytical, verbal, and written communication skills.
• Effective project management skills to create and execute work plans.
• In person as needed.
• Ability to work independently and in a team environment.
• Ability to manage multiple tasks
• Proficient in relevant PC applications (Share point, Care Advance, NASCO, 3270, MCMS/AMP and IKA.
• Basic knowledge of ICD9/ICD 10 and CPT Codes.
• Care Advance and NCQA.
• Knowledge of local, and state regulations (PA250, PA350, DOL, ERISA, HIPPA, CMS). 
• Leadership experience. 
• In depth understanding of BCBSM benefits and their application.
• Ability to use clinical assessments and interventions. 
• Knowledge of effective communication techniques and theories. 
• Knowledge of utilization management, InterQual and medical policy knowledge.
• Must be willing to act as a “change agent” on behalf of area and positively support the inception of new programs, systems, processes, software, and tools.
• Excellent organizational skills, multi-tasking and timelines with planning and development required.
• Demonstrated problem solving and decision-making skills. 

Departmental Preference

• Two (2) years medical policy or clinical review coordination experience preferred.
• Knowledge of local, state regulatory and designated accreditation standards (NCQA) preferred.
• Knowledge of policies and procedures, member certificates (riders, waivers, exclusions and limitations) preferred

Qualifications

• Nursing Diploma or associate’s degree in nursing required. 
• Bachelor’s degree in nursing (BSN) or related fields preferred.
• Five (5) years of experience in health-related fields required.
• Three (3) to five (5) years’ internal experience with Care Management and/or Utilization Management

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.