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The Grievance Nurse is responsible for investigation, monitoring and reporting of Quality of Care, Quality of Service and Serious Reportable Adverse Events according to Center for Medicare and Medicaid Services (CMS) guidelines and plan policies and procedures. The Grievance Nurse will complete medical record reviews for re-credentialing and support activities related to Quality Improvement initiatives.
Roles and Responsibilities:
Conducts review of member grievances related to Quality of Care and Quality of service issues
Prepares reports to support CMS reporting requirements for quality topics such as Serious Reportable Adverse Events
Conducts medical record reviews to support regulatory requirements for the purposes of re-credentialing, Star Ratings and Medicare quality indicator reporting as needed.
Extracts, collects, analyzes and summarizes performance data for quality of care issues, quality initiatives, surveys, and audits
Performs comprehensive and accurate documentation to ensure grievances are handled in accordance to CMS guided regulations
Performs provider and member outreach
Assists in preparing for internal and external audits
Recognizes urgent issues and escalates to management in a timely manner to help facilitate a response
Participates in Quality Improvement initiatives
Performs other duties as assigned to meet departmental and company objectives
Experience, Qualifications, and Education:
Bachelor's Degree in a health-related field
2+ years of experience in Quality Improvement
2+ years of experience in Managed Care
2+ years of experience with regulatory-required initiatives
Proficiency with clinical data management and statistical quality tools
Proficiency with MS Office applications
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
Excellent verbal and written communication skills
Ability to work independently and meet deadlines
Ability to operation in fast paced and dynamic environment
Collaborative and team orientated
Strong logical and critical thinking skills
Lumeris is an EEO/AA employer M/F/V/D.
St. Louis, MO