Clinical - Exception Template

Quality of Care Coordinator - 112044?
"Position Purpose:
Review medical records for potential Quality of Care (QOC) incidents, applying clinical criteria to determine if a lack of care was present. Utilize clinical knowledge to provide summary of findings and severity level to physicians.

Education/Experience:
Associate s degree in Nursing required; Bachelor s degree in Nursing preferred. 3+ years of experience in nursing or related healthcare experience.

License/Certification:
RN/LCSW required; CPHQ preferred"
"Review medical records for quality of care incidents by determining if the specified standards of care were met, and assigning an initial severity level of lack of compliance/care
Compile timeline and summary of incident, including the details of the potential QOC for presentation to the medical director for a final review; may also be involved in peer review committee actions or next steps
Maintains organizational and program policies and procedures; ensures adherence to prescribed policies and procedures and clinical protocols where appropriate"

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

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Quality of Care Coordinator - 112044 "Position Purpose: Review medical records for potential Quality of Care (QOC) incidents, applying clinical criteria to determine if a lack of care was present. Utilize clinical knowledge to provide summary of findings and severity level to physicians. Education/Experience: Associate s degree in Nursing required; Bachelor s degree in Nursing preferred. 3+ years of experience in nursing or related healthcare experience. License/Certification: RN/LCSW required; CPHQ preferred" "Review medical records for quality of care incidents by determining if the specified standards of care were met, and assigning an initial severity level of lack of compliance/care Compile timeline and summary of incident, including the details of the potential QOC for presentation to the medical director for a final review; may also be involved in peer review committee actions or next steps Maintains organizational and program policies and procedures; ensures adherence to prescribed policies and procedures and clinical protocols where appropriate"
Story Behind the Need
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		The Quality of Care Coordinator (RN) plays a critical role in supporting Critical Incident (CI) and Quality of Care (QOC) investigations, regulatory reporting, clinical review, monitoring, corrective action oversight, and follow-up activities. The need for this position has increased as Critical Incident reporting volume has grown approximately 35% year over year, driven in part by expanded DMMA reporting requirements and increased regulatory oversight. Critical Incident management requires timely review, investigation, reporting, monitoring, provider outreach, corrective action follow-up, and case closure activities, all of which require clinical expertise and judgment. Timely reporting and ongoing monitoring of Critical Incidents are contractual and regulatory obligations. This position is necessary to maintain adequate clinical capacity to support compliance requirements, member safety oversight, timely regulatory reporting, and effective management of the Critical Incident and Quality of Care programs. Dedicated RN resources are required to support ongoing reporting, monitoring, investigation, and follow-up activities and ensure sustainable operational performance.
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?			2 - Headcounts Quality of Care/Critical Incidents Nurse Checking email box daily for Critical Incident referrals Entering referrals into the Delaware state tool Creating and completing assessments of the assigned member Communicating with the care coordination team regarding the status of the assigned member Updating tracker of assigned members And other tasks based on needs 1 - Headcount Appeals and Grievance Nurse Coordinating complex appeals case Conducting clinical reviews Supporting medical necessity determinations Collaborating with medical doctors Ensuring compliance with state federal and contractual requirements Tracking and documenting statuses And other tasks based on needs
Candidate Requirements
Education/Certification	Required: Associate s degree in Nursing				Preferred: Bachelor s degree in Nursing
Licensure	Required: RN any state				Preferred: Compact
Years of experience required: 3+ years of experience in nursing or related healthcare experience Disqualifiers: Big gaps in work experience, terminated due to poor performance Additional qualities to look for: high performer
Top 3 must-have hard skills stack-ranked by importance			1	Willingness to learn
			2	Team player Good communication skills
			3	Ability to work MS Word and Excel efficiently
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations			Projected Manager Candidate Review Date:			ASAP
			Type of Interviews:			1 Teams Camera on
			Required Testing or Assessment (by Vendor):