Nurse, Quality Assurance CFHP (PRN)

JOB TITLE: Nurse, Quality Assurance ? Health Services Management CFHP
JOB CLASS NUMBER: 4176 (PRN 4177)
REVISED: 01/10


POSITION SUMMARY/RESPONSIBIILITIES
Plans, coordinates and implements the Quality Management and Improvement Program and the Utilization Management Program Plan for Community First with focus on pended claims and appeals, UM related complaints and adverse determination appeals and quality assurance activities to support health services, such as training and auditing. Reviews, evaluates and processes all Health Services Management (HSM) pended claims and appeals and/or UM or health services complaints; implements quality assurance activities related to training and auditing of HSM staff; and identifies opportunities for improvement. Provide administrative and technical/system support for utilization and quality management activity as appropriate. Complies with Health System, CFHP and area policies, procedures and protocols for establishing and maintaining good working relationships with co-workers and Health System employees, patients and guests.

EDUCATION/EXPERIENCE
Graduation from an accredited college or university with a bachelor's degree in nursing is required. Four years of progressively responsible experience along with an associate's degree in nursing may be substituted in place of a bachelor's degree. Experience in a managed care setting is required. Working knowledge of complaints/appeals, ICD9, CPT4 coding InterQual/M&R criteria, Texas Department of Insurance HMO standards and NCQA standards is required.

LICENSURE
Current license from the Board of Nurse Examiners of the State of Texas to practice as a registered nurse is required. A valid Texas Drivers License and a reliable vehicle are required.