Consultant-Nurse

Essential Duties and Responsibilities: CA DMHC Medical Survey and CA DMHC BHIs Responsibilities:

• Oversee medical survey and/or investigation teams, and participate in surveys or investigations if needed
• Prepare to survey (audit) managed healthcare plans in utilization management, emergency services, pharmacy, grievances and appeals, access and availability, and language assistance; prepare for BHI Investigations
• Review and analyze managed healthcare plan documents, including but not limited to policies, procedures, organizational charts, meeting minutes, training, and job aids.
• Complete client-developed audit tools
• Perform detailed analysis, fact-finding, and documentation of evidentiary support for findings.
• As applicable, perform a detailed case file review to audit whether the plan is performing as indicated in its policies and complete the client-developed tool that walks the surveyor/investigator through clinical and legal requirements
• Attend pre-onsite meetings with client team to discuss preliminary findings
• Prepare for and interview plan staff at managed healthcare plan offices or remotely.
• Lead interviews with plan staff and the client team (team lead, oversight manager, and attorney) to obtain relevant evidence to support findings
• Complete and update audit tools with information obtained through the site visit or interviews
• Identify potential plan deficiencies for survey areas/barriers or violations for investigations
• Request additional documentation and/or interviews, as needed.
• Draft report of deficiencies for survey area or barriers/violations for investigations
• Address feedback and/or questions from the client regarding findings in the report
• Prepare cost estimates

-Recommend changes to policies and established procedures-

• Develop, monitor, and use quality control procedures and audit criteria to ensure consistent application of contractual requirements and established policies and procedures
• Interact with different levels of external and internal customers

Minimum Requirements

• Bachelor's degree or equivalent combination of education, technical training or work experience considered in lieu of degree
• Registered Nurse degree with active license required - Minimum five (5) years of related experience required
• Minimum three (3) years of people management experience
• Experience conducting medical surveys and BH investigations
• Excellent organizational, interpersonal, written and verbal communication skills
• Ability to perform comfortably in a fast-paced, deadline-oriented work environment
• Ability to successfully execute many complex tasks simultaneously
• Ability to work as a team member, as well as independently

Additional Information

• Location – While the client is in CA, the candidate can live anywhere in US.
• Travel – average 1 to 2 weeks per month, when needed for onsite interviews
• Expenses – Travel, Training, and Finger Printing will be paid for by ***

• Background – 1 year Managed Healthcare/Worked in a hospital/Case Manager/Diverse work history

• Status – Part Time; average 10 – 15 hours per week’ could be more due to travel
• Pay Rate: ***

• Training: Begins with one on one with Nurse manager then observation of a Survey (no travel required). Employee then assigned survey(s) per annual schedule with preceptorship with experienced RN. Type: Long Term Contract (approximately 5 years); could be converted over time Apply Job! Apply to this Job