Consultant-Nurse

CA DMHC Medical Survey and CA DMHC BHIs Responsibilities:
-Oversee medical survey and/or investigation teams, and participate in surveys or investigations if needed
-Prepare to survey (audit) managed healthcare plans in utilization management, emergency services, pharmacy, grievances and appeals, access and availability, and language assistance; prepare for BHI Investigations
- Review and analyze managed healthcare plan documents, including but not limited to policies, procedures, organizational charts, meeting minutes, training, and job aids.
- Complete client-developed audit tools
-Perform detailed analysis, fact-finding, and documentation of evidentiary support for findings.
- As applicable, perform a detailed case file review to audit whether the plan is performing as indicated in its policies and complete the client-developed tool that walks the surveyor/investigator through clinical and legal requirements
-Attend pre-onsite meetings with client team to discuss preliminary findings
-Prepare for and interview plan staff at managed healthcare plan offices or remotely.
-Lead interviews with plan staff and the client team (team lead, oversight manager, and attorney) to obtain relevant evidence to support findings
-Complete and update audit tools with information obtained through the site visit or interviews
-Identify potential plan deficiencies for survey areas/barriers or violations for investigations
-Request additional documentation and/or interviews, as needed.
-Draft report of deficiencies for survey area or barriers/violations for investigations
- Address feedback and/or questions from the client regarding findings in the report
-Prepare cost estimates
-Recommend changes to policies and established procedures-
-Develop, monitor, and use quality control procedures and audit criteria to ensure consistent application of contractual requirements and established policies and procedures
-Interact with different levels of external and internal customers

Minimum Requirements
- Bachelor's degree or equivalent combination of education, technical training or work experience considered in lieu of degree
- Registered Nurse degree with active license required - Minimum five (5) years of related experience required
- Minimum three (3) years of people management experience
-Experience conducting medical surveys and BH investigations
-Excellent organizational, interpersonal, written and verbal communication skills
-Ability to perform comfortably in a fast-paced, deadline-oriented work environment
-Ability to successfully execute many complex tasks simultaneously
-Ability to work as a team member, as well as independently

Additional Information
- Location While the client is in CA, the candidate can live WEST Coast, Mid-west, TX
- Travel average 1 to 2 weeks per month, when needed for onsite interviews
- Expenses Travel, Training, and Finger Printing will be paid for by client.
- Background 1 year Managed Healthcare/Worked in a hospital/Case Manager/Diverse work history
- Status Part Time; average 10 15 hours per week could be more due to travel
- Training: Begins with one on one with Nurse manager then observation of a Survey (no travel required). Employee then assigned survey(s) per annual schedule with preceptorship with experienced RN.
Type: Long Term Contract (approximately 5 years); could be converted over time