Job Description
Position Summary MUST WORK IN OUR OFFICE IN POMONA, CA The LVN / RN Quality Improvement role provides leadership and oversight for BLEHEALTH’s Quality Improvement (QI), Performance Improvement (PI), Compliance, Risk Management, Patient Safety, and Care Management quality functions. This role works in close partnership with the RN Clinical Director and Clinical Oversight Senior Manager to ensure clinical accuracy, documentation quality, care gap closure, and continuous improvement in member outcomes. The LVN or RN QI role ensures organizational readiness for audits, regulatory compliance, accreditation standards, and health plan requirements. This position supports clinical oversight by reviewing charts, validating care plans, monitoring care delivery, and ensuring documentation completeness to prevent avoidable hospitalizations through proactive intervention. This role requires strong clinical judgment, regulatory expertise, analytical skills, and the ability to lead teams through continuous improvement processes while supporting BLEHEALTH’s mission, vision, and values. Key Responsibilities Quality Improvement & Performance Improvement Lead the development, implementation, and evaluation of BLEHEALTH’s Performance Improvement Program. Ensure member charts are complete, compliant, and audit ready by working directly with Lead Care Managers, CHWs, Housing Navigators, and QI Coordinators. Oversee documentation quality—including assessments, care plans, referrals, and progress notes—by reviewing charts and ensuring accuracy, completeness, and regulatory compliance. Provide clinical guidance and feedback to staff regarding documentation quality, care gap closure, and regulatory requirements. Collaborate with staff and supervisors to correct deficiencies and ensure continuous improvement in documentation practices. Support QI Coordinators in chart audits, data validation, and readiness for internal and external reviews. Develop and maintain the QI work plan, reporting calendar, and performance measurement systems. Conduct data collection, aggregation, analysis, and reporting for clinical and operational metrics. Lead improvement cycles using PDSA, Lean, Six Sigma, or similar methodologies. Identify performance gaps and implement corrective action plans. Ensure continuous audit readiness and compliance with regulatory, accreditation, and health plan requirements. Oversee HEDIS and non-HEDIS data collection, tracking, trending, and reporting. Monitor medical record completeness, documentation quality, and audit outcomes. Facilitate staff training on QI tools, documentation standards, and performance initiatives. Promote a culture of continuous quality improvement across BLEHEALTH. Regulatory Compliance & Accreditation Maintain current knowledge of CDPH, CMS, MediCal, CalAIM, and accreditation standards. Ensure compliance with all regulatory requirements and health plan contracts. Prepare and submit mandatory reports to regulatory agencies. Coordinate internal and external audits, including documentation requests and corrective action plans. Maintain BLEHEALTH’s Compliance Program, including annual evaluations and updates. Respond to Statements of Deficiencies, Plans of Correction, grievances, and complaints within required timelines. Ensure policy and procedure standards comply with local, state, and federal regulations. Coordinate continuous readiness for Joint Commission, DHCS, MEDI-CAL, and health plan audits. Risk Management & Patient Safety In collaboration with the HR Manager, oversee BLEHEALTH’s Risk Management Program, including incident reporting, investigations, and followup. Conduct Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA). Develop and maintain the Patient Safety Program and related policies. Collaborate with clinical leadership on sentinel events, near misses, and adverse events. Ensure timely completion of incident reports and corrective actions. Maintain risk management documentation, corrective action plans, and followup activities. Clinical Quality Oversight & Care Gap Management Support clinical leadership by reviewing member charts for clinical accuracy, care gaps, and adherence to care plans. Ensure care plans are clinically appropriate, updated, and aligned with member needs and regulatory requirements. Verify that care is being delivered as documented and that interventions are timely and evidence based. Conduct targeted chart audits to ensure completeness, accuracy, and compli