Measurement Technician III

Department(s): Quality Improvement
Reports to: Manager, Quality Improvement (PQI)
FLSA status: Non - Exempt
Salary Grade: M - $85,000 - $141,086

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Wednesday, October 18, 2023 at 11:59 PM
. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

Cal Optima Health is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together." — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join Cal Optima Health.

The QI Nurse Specialist-Potential Quality Issue (PQI) is responsible for participating in handling the organization’s quality of care grievance review process, including investigation of all quality reviews for potential quality of care concerns. The incumbent will be involved with the collection of appropriate data and closing cases by preparing and submitting the cases to the appropriate physician reviewer and committees for closure.

The incumbent ensures grievances/complaints and PQIs are processed in accordance with regulations, compliance standards and policies and procedures.

• Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
• Ensures integrity of departmental database by thorough, timely and accurate entry of cases.
• Participates in departmental meetings, trainings and audits as requested.
• Assists with the intake of cases in the department.
• Reviews productivity and timeliness for quality of care grievances and PQIs through the use of reports.
• Performs investigations of unusual occurrences/events from sources (providers, staff, hotline, etc.) and assesses the criticality of events.
• Maintains and supports a culture of compliance, ethics and integrity.
• Maintains knowledge of policies and procedures and performs in accordance with applicable regulatory requirements, external laws and accreditation standards as they relate to business and clinical risk management.
• Performs clinical assessments of member complaints and intervenes as needed for urgent clinical issues.
• Develops a thorough clinical review and written report for cases referred for PQI investigations.
• Completes other projects and duties as assigned.

• Bachelor’s degree in Nursing or Health Services required.
• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.
• 5 years of experience in patient care required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

• Certification in Case Management (CCM) or Certified Professional in Healthcare Quality (CPHQ).
• 2 years of experience in a managed care setting.
• Project management skills.

• Physical demands:
  While performing duties of the job, employee may need to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Employee must be able to communicate, particularly for regular phone use.
• Work Environment:
  Typical office…