Quality of Care and Clinical Review Nurse

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary Under the supervision of the Quality of Care (QOC) Manager, the QOC Nurse conducts the review and investigation of potential quality of care issues in a timely, and efficient manner. The QOC Nurse is responsible for conducting quality improvement/management activities in accordance with state and federal regulatory requirements, including, but not limited to, Centers for Medicare and Medicaid Services (CMS), State and National Committee for Quality Assurance (NCQA). Required Job Qualifications Registered Nurse (RN) with unrestricted license in state of operations. 5 years combined knowledge of healthcare processes. Knowledge of managed care processes. Organizational skills and ability to meet deadlines and manage multiple priorities. Verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers. PC experience to include Microsoft Word, Access, and Excel. Strong knowledge of common patient disease processes and usual methods of treating them; Thorough knowledge of medical terminology and commonly used equipment; Ability to effectively evaluate medical records for appropriateness