Q.I. Nurse

The Quality Improvement Nurse oversees the daily operations of the QI department and is responsible for the execution and coordination of all QI activities. Interfaces with other departments and Health Plans for QI issues.

Review daily grievance and appeals from health plans, providers or members and request in writing to the appropriate facility or provider for any records and a response. Review with Medical Director on each case to determine leveling. Update Grievance Appeal Logs daily and report to appropriate committees monthly. Report statistical information on quality issues tracked by health plan and report monthly to the QI Committee. Identify and act upon any provider/vendor trends immediately and informs Medical Director and QI Committee. Prepare and develop annual QI study tools, gather and report statistical results to QI Committee, governing board and health plans. Study will be decided by QI Committee each year. Participate and provide information for QI Plan and semi-annual coalitions. Implement annual QI study approved by QI Committee with policy, process flow, and action plan and report results when completed. (Access audits / coalitions / HEDIS) Conduct Access and Availability audits per health plan request. Maintain departments access audits to include CSR, health plan or internal complaints. Ensure access and availability log is updated weekly with trends reported to QI committee with follow-up and closure to be compliant. Schedule appointments with physician offices and ancillary facilities for site reviews (facility and medical charts) as requested by the Credentialing Department. Send confirmation letter with set appointment date and the site audit tool prior to appointment to provider office. Report within 48 hours to the Credentialing Department the provider offices that do not meet threshold requirements for the audit and provide a copy of the review and notes after site audit is completed.