RN, Quality Improvement

This position is intended to start January 2026.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work - Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP's focuses on 5 Core Values in the workplace:

* Integrity

* Accountability

* Collaboration

* Trust

* Respect

Disclaimers:

* Flexible work schedule is based on job duties, department, organization, or business need.

* Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The RN, Quality Improvement (QI) will support the Quality Improvement and Health Services Programs, assisting the health plan to successfully achieve organizational objectives for clinical quality and patient safety. This position will be responsible for core clinical and regulatory compliance functions within the QI and Health Services arena, including Facility Site Review (FSR) Medical Record Review (MRR), Potential Quality Issue (PQI) investigation and reporting, and liaison with the team in designing and implementing clinical quality improvement strategies and interventions to support quality metrics and regulatory requirements. The RN, Quality Improvement I will work closely with the Health Services leadership team and the Chief Medical Officer to assess the Program's outcomes, identify areas of needed improvement, and institute actions to promote the delivery of high-quality care. This employee must be able to interpret the requirements of the Plan's regulatory bodies, and state and federal regulations, NCQA accreditation standards, and institute processes/programs to ensure compliance.

Amount of Travel Required: 30-50%

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

* Work closely with other departments of the Health Plan, Health Services and Ql team, and Chief Medical Officer to achieve the goals of the Quality Improvement and Health Equity Transformation (QIHET) Program by identifying issues and implementing corrective actions to ensure compliance with DHCS regulatory requirements and optimize GCHP quality performance.

* Lead the timely investigation, processing, and reporting of identified potential quality issues (PQI following the Plan's procedures and timelines).

* Track and trend PQI outcomes for the purpose of reporting and prioritization of improvement actions/interventions.

* Annually review and edit relevant policies and procedures per APL updates, regulatory requirements, NCQA standards and/or required process changes.

* Conduct facility site reviews (FSR), Medical Record Reviews (MRR), and/or Physical Accessibility Review Surveys (PARS) according to DHCS site survey requirements and maintain the FSR database for ongoing tracking of contracted sites and reporting purposes.

* Ensure timely follow up on all FSR/MRR activities, including provider communication and corrective action plan documentation.

* Lead and/or participate in quality improvement activities and audits, including but not limited to, focused medical record review (MRR), monitoring of Initial Health Appointment (IHA), blood lead screening in children, and other performance improvement projects.

* Participate and/or provide clinical support to regulatory compliance activities, including but not limited to, DHCS Medical Audits, HEDIS compliance audits, and internal/external audits.

* Support, as needed, the annual HEDIS project, including medical record abstraction and over-reads to determine compliance with HEDIS measures and optimize performance outcomes.

* Utilize clinical expertise to create and/or revise policies and procedures per new APL requirements, regulatory requirements, and/or NCQA standards, establish QIHET work plan metrics and key performance indicators, implement provider training programs, and develop member and provider newsletter and website content.

* Lead, facilitate and/or participate in relevant committees and work groups; prepare reports, data, or other materials for committee presentation.

* Complete project-related communications, including job aides, member/physician communications, website content, work plans/action plans, graphical analyses, and agendas/minutes, as applicable.

* Research best practices, and industry standards to help promulgate quality outcomes for the Plan.

* Demonstrate strong critical thinking, collaboration, and work ethic, with the ability to foster teamwork and work effectively with providers and multi-disciplinary teams, and adapt quickly to changing priorities

* Perform all other duties as assigned.

MINIMUM QUALIFICATIONS

Education & Experience:

Required Education and Experience

* Current CA Registered Nursing License - Unencumbered

* Associate or bachelor's degree (two or four-year college or technical school) Required, Field of Study: Nursing

* 1-2 years of clinical experience in Quality Improvement, Risk Management, Compliance, and/or Accreditation demonstrating increasing responsibility in clinical quality improvement.

KNOWLEDGE, SKILLS & ABILITIES

* Analytical and problem-solving acumen.

* Critical thinking skills

* Excellent verbal and written communication skills and ability to interact in a positive manner within the medical/clinic community.

* Team player who builds effective working relationships within and across teams.

* Ability to work independently.

* Strong organizational skills

* Ability to analyze, interpret, apply, and communicate policies, procedures and regulations.

* Understanding and ability to perform data analysis, basic statistical skills including intermediate knowledge of Excel.

* Proven experience with performance improvement methodologies required.

PREFERRED QUALIFICATIONS

* Public Health and/or ambulatory care/clinic setting background

* Medicaid Health Plan experience

* Certified Facility Site Reviewer or FSR experience

* Knowledge of quality improvement processes and risk mitigation strategies in a managed care environment.

* Knowledge of DHCS requirements, NCQA Accreditation standards, and HEDIS.

Technology & Software Skills:

* Highly competent in the MS Office products including proficiency in Word, Excel, PowerPoint, and databases.

* Working knowledge with electronic health record systems including Cerner, NextGen, and Meditech.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and Current CA Registered Nurse licensure(s)

Competency Statements

* Business Acumen - Ability to grasp and understand business concepts and issues.

* Decision Making - Ability to make critical decisions while following company procedures.

* Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

* Interpersonal - Ability to get along well with a variety of personalities and individuals.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

* Consensus Building - Ability to bring about group solidarity to achieve a goal.

* Relationship Building - Ability to effectively build relationships with customers and co-workers.

* Presentation Skills - Ability to effectively present information publicly.

* Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

* Judgment - The ability to formulate a sound decision using the available information.

* Communication, Oral - Ability to communicate effectively with others using the spoken word.

* Communication, Written - Ability to communicate in writing clearly and concisely.

* Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.