Job: Nurse, Quality Assurance Health Services Management CFHP

Department: HSM-Resolution Unit
Location: Community First Health Plans

JOB CLASS NUMBER: 4176
REVIEWED:11/08

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 bachelors degree in nursing is required. Five years of progressively responsible experience along with an associates degree in nursing or a licensed vocational nurse may be substituted in place of a bachelors 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 nursing licensure in the State of Texas is required. A valid Texas Drivers License and a reliable vehicle are required.