QA Investigative RN

JOB DESCRIPTION-DUTIES Concerns regarding member care and/or service delivery requires immediate follow-up and resolution by the Division. The resolution of quality of care concerns (QOC) requires a thorough gathering of documentation, review and analysis of data collected from various entities. This can include Support Coordination, Incident Investigators, Health Plans, Behavioral Health, Providers, Protective agencies and other involved parties. Review of records could include medical evaluations, member files, protective agency and/or law enforcement reports and provider records. Analysis of incidents that resulted in the care/service concern could identify abuse, neglect, training and/or systemic issues within the Division or associated providers. This process is addressed in a planned, consistent manner which will result in the elimination or reduction of incidents for members served by the Division. As a Program Contractor of AHCCCS, the Division must ensure member safety, timely and appropriate service delivery or be at risk of possible sanctions. 

This position investigates concerns regarding care or service delivery from an individual and systemic perspective. The expectation from the comprehensive review is measurable improvement in the quality, oversight of services and an improvement in the health, safety and quality of life of individuals served by the Division. All quality of care concerns (QOC)are reported to AHCCCS and a comprehensive written response is provided back that indicates the investigative findings, interventions taken to resolve concern and the level of risk substantiated concerns imposed on the member within established time lines. This position also conducts trending to determine success of interventions and makes recommendations for continuous improvement. Must maintain confidentiality and conduct reviews of QOCs in an objective manner. 

In addition, the position prepares and presents cases to the Peer Review Committee. This position also leads or participates in initiatives as a result of identified trends, committee recommendations, as part of Strategic plan, etc. Conducts Root Cause Analyses to determine facts/cause of negative outcomes which includes interviewing members and other parties involved in the incident. Position participates in annual audits, develops/revises policy and procedures and quality meetings as requested.