LPN - Quality of care Investigative Nurse

The first day requires in-person attendance to obtain equipment and complete necessary security training for system access. Subsequent onboarding and training will be conducted remotely. The work schedule is 8am-5pm, Monday through Friday, totaling 40 hours per week.

• This position reports to the Quality Management Unit and conducts quality-of-care investigations in accordance with contractual obligations.
• Participates in investigations of member-centric and systemic quality-of-care concerns to ensure member health and well-being.
• Conducts timely, thorough investigations of quality-of-care issues and implements vendor-specific corrective action plans using a standardized process. Makes appropriate referrals to oversight and regulatory agencies.
• Participates in care concerns and member issue investigations as assigned.
• Maintains all necessary documentation to support case work.
• Requests appropriate documentation for quality-of-care investigations and ensures comprehensive case records are maintained to support allegation review and substantiation levels.
• Issues remediation or a corrective action plan to the vendor as a result of investigations and ensures all applicable information and documents are uploaded within the designated portal. Appropriately elevates cases and/or trend concerns to the supervisor.

• Critical thinking
• Technological skills, including the use of databases, Microsoft Office products, email, and electronic referral and verification sources
• Producing professional technical reports and letters
• Research and analysis
• Oral and written communication skills
• Personal planning, organization, and time management
• Medical chart review
• Nursing process, including assessment, monitoring, and evaluation
• Decision-making skills
• Critically analyze problems and develop effective plans for corrective action

• Active license to practice as an LPN