Location Address:

9521 San Mateo NE
Albuquerque, NM 87113-2237


Compensation Pay Range:

Minimum Offer $60,985.60
Maximum Offer $103,812.80
Now Hiring: Clinical Quality of Care Coordinator

Summary:

Responsible for Quality of Clinical Care activities. Coordinates the provider peer review process which assesses and reviews the quality of patient and member care provided by direct care providers and facilities. Investigates all complaints alleging inappropriate clinical care or alleged inappropriate behavior by a physician or other health care practitioner/provider. Applies the knowledge of a registered nurse to determine the key factors in each case and whether the standard of care has been met, documenting and summarizing findings for all parties regarding investigative findings. Collaborates with other staff including medical directors, registered nurses, and legal counsel.

Type of Opportunity: Full time
Job Exempt: Yes
Job is based: Reverend Hugh Cooper Administrative Center
Work Shift: Days (United States of America)


Responsibilities:

• Coordinates tracking and trending of data for QOC, reporting to appropriate internal committees and bodies as well as external agencies.
• Collaborates closely with internal stakeholders.
• Develops and refines processes, policies and procedures, and desktop tools. Supports implementation of change projects/initiatives. Supports the development and implementation of the department strategic plan.
• Reviews, responds to, and researches complaints related to quality of medical care utilizing a high level of knowledge and skill in nursing practice in order to discern the key factors in each case to ensure that all quality of care issues are identified and addressed. Provides appropriate referrals to Legal/Risk Management for potential legal or at risk issues, Health Services Care Coordination for members at risk, and Provider Network Management for identified service issues.
• Presents the facts of the case and makes recommendations to the Peer Review Committee for cases involving quality of care issues. Takes appropriate action based on committee decision, such as practitioner quality chart reviews to determine individual practice patterns in order to evaluate performance against the standard of care and peer group performance.
• Develops and maintains a formalized process for sharing of quality of care practitioner information at an enterprise level working with legal, credentialing, medical staff affairs, provider network management, and the medical group.
• Develops and maintains process for internal and external peer review in consultation with legal. This may require identifying external practitioners for specialty being reviewed, contacting practitioner for ability to act in this capacity, making financial arrangements for services, and handling all logistics to send and receive peer review opinions.
• Manages the quality of care database for occurrence screening, quality of care reporting, and to monitor and evaluate issues as a network. Uses the data to drive decisions and plan/implement performance improvement strategies.
• Develops training materials to address individual and network-wide improvement opportunities and collaborates with Provider Services staff to develop and implement the approach that will be most effective in influencing practice.
• Advises leadership in the identification of system processes that could be improved to maximize patient safety, optimize positive patient outcomes, and minimize financial loss. Participates on process improvement teams as appropriate.
• Performs other functions as required, i.e. cross-training with Critical Incidents, clinical quality projects.

Qualifications:

• Current New Mexico RN License required.
• Bachelors degree required, BSN preferred.
• Three to five years experience in clinical nursing field required, three years quality improvement experience preferred.
• Three years case management or care coordination experience preferred.
• Excellent written, oral, and facilitation skills required.
• Skills in Word, Excel, and Power Point necessary..
• Demonstrates ability to work with highly sensitive and confidential information.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services