The Grievance Nurse is responsible for investigation, monitoring and reporting of Quality of Care, Quality of Service and Serious Reportable Adverse Events according to Center for Medicare and Medicaid Services (CMS) guidelines and plan policies and procedures. The Grievance Registered Nurse will complete medical record reviews for re-credentialing, assist with inter rater reliability in conjunction with the HEDIS Medical Record Review Project and support activities related to Quality Improvement initiatives.
Roles and Responsibilities:
- Conducts review of member grievances related to Quality of Care and Quality of service issues.
- Prepares reports to support CMS reporting requirements for quality topics such as Serious Reportable Adverse Events.
- Conducts medical record reviews to support regulatory requirements for the purposes of re-credentialing, HEDIS, Star Ratings and Medicare quality indicator reporting as needed.
- Extract, collect, analyze and summarize performance data for quality of care issues, quality initiatives, HEDIS, surveys, and audits.
- Strong desire for member advocacy and education.
- Participates in Quality Improvement initiatives.
- Performs other duties as assigned.
Experience, Qualifications, and Education:
- RN or LPN required
- Bachelor’s Degree in a health related field
- Grievance experience is strongly preferred
- 2+ years of experience in Quality Improvement
- 2+ years of experience in Managed Care
- 2+ years experience with regulatory-required initiatives (e.g., HEDIS, CAHPS)
- Proficiency with clinical data management and statistical quality tools
- Proficiency with MS Office applications
- Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
- MUST be able to critically think with excellent verbal and written communication skills
- Thrive in a fast paced work environment