Job description

POSITION DESCRIPTION

POSITION TITLE:
Medical Management Nurse Analyst (Non Exempt)

POSITION SUMMARY:
This position is responsible for assisting the Director of Medical Management Services and the Chief Medical Officer in gathering, analyzing and reporting clinical data as outlined in the CalViva Quality Improvement and Utilization Management Work Plans and Program Descriptions. This individual also assists with internal and external audits or audit validation reviews of varying complexity and scope.

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Assists in maintaining standards that are in conformance with federal and state regulations and requirements.
• Gather, review and monitor regular clinical reports from Health Net.
• Perform (or assist with) annual oversight audits of HN clinical functions.
• Assist with preparation for external audits (DHCS, DMHC, NCQA) by gathering and reviewing required documents for clinical functions.
• Prepare/assist with audit summary reports and the implementation of any required corrective action plans.
• Participate as requested in HEDIS® Projects, the DHCS required Quality Improvement Projects, and other QI or UM activities, studies, reviews and surveys.
• Assist in the preparation of required CalViva clinical reports.

MINIMUM QUALIFICATIONS:
EDUCATION:
Completion of an accredited nursing program

LICENSES:

• Current California nursing license (R.N. OR L.V.N.)
• QI program certification a plus
• Current driver’s license

EXPERIENCE:

• Minimum of two years’ experience in healthcare environment.
• Health Care Quality Improvement and/or auditing experience.

KNOWLEDGE, SKILLS & ABILITIES:

• Ability to effectively develop, analyze, interpret, and communicate healthcare data reports and processes.
• Strong analytical and problem-solving skills.
• Must be proficient in Microsoft Office: Word, Excel, PowerPoint, Access and Outlook.
• Possess the ability to prioritize projects appropriately and multi-task.
• Ability to take initiative and work independently.
• Effective organizational and communication skills.
• Team player who can establish and maintain effective working relationships at all organization levels.
• Exercise a high degree of maturity, integrity, loyalty, initiative, creativity and sound judgment.

Physical Requirements

• Constant and close visual work at desk or computer.
• Extensive typing
• Constant sitting and working at desk.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent walking and standing.
• Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lb.
• Must have reliable transportation, may be required to travel between Kings, Madera and Fresno counties as well as between offices for meetings

Note: The information in this position description indicates the general nature and level of work performed by employees within this classification. It is not designed to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.

Job Type: Full-time

Pay: $60,000.00 - $80,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Experience:

• Healthcare environment: 2 years (Required)

License/Certification:

• RN License (Preferred)

Work Location: One location

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