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 To this Job   Apply for this job