Sr Specialist, Quality Improvement (RN) - Remote
About the position
The Senior Specialist, Quality Improvement (Registered Nurse) at Passport Health Plan by Molina Healthcare plays a crucial role in overseeing, planning, and implementing healthcare quality improvement initiatives and education programs. This position is responsible for ensuring that programs for members are maintained in accordance with prescribed quality standards. The Senior Specialist conducts data collection, reporting, and monitoring for key performance measurement activities, and provides direction for the implementation of NCQA accreditation surveys and federal/state quality improvement compliance activities. In this role, the Senior Specialist contributes to various quality improvement functions, including Quality Interventions, Quality Improvement Compliance, HEDIS, and Quality Reporting. As a lead specialist, the Senior Specialist provides project, program, and initiative-related direction and guidance for other specialists within the department and collaborates with other departments. The position requires the implementation of key quality strategies that necessitate near real-time clinical decision-making, which may involve initiating and managing interventions, preparing for Quality Improvement Compliance surveys, and reviewing medical record documentation for credentialing and model of care oversight. The Senior Specialist is also responsible for monitoring and ensuring that key quality activities involving clinical decision-making are completed accurately and on time. This includes writing narrative reports to interpret regulatory specifications, explaining programs and results, and documenting findings and limitations of department interventions. The role involves leading quality improvement activities, meetings, and discussions with other departments, surfacing any gaps in processes that may require remediation, and focusing on areas where a clinician's perspective is valuable. Additionally, the Senior Specialist performs the lead role in coordinating and preparing for the HEDIS medical record review, which includes ongoing reviews of records submitted by providers and the annual HEDIS medical record review. The position requires participation in meetings with vendors for the medical record collection process, assisting in training, and providing data collection and report development support for quality improvement studies and performance improvement projects. The Senior Specialist also assists in accreditation activities such as NCQA reviews, CAHPS, and state audits by reviewing clinical documentation.
Responsibilities
Oversee, plan, and implement healthcare quality improvement initiatives and education programs.
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Ensure maintenance of programs for members in accordance with prescribed quality standards.
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Conduct data collection, reporting, and monitoring for key performance measurement activities.
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Provide direction for the implementation of NCQA accreditation surveys and federal/state quality improvement compliance activities.
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Act as a lead specialist to provide project, program, and initiative-related direction and guidance for other specialists.
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Implement key quality strategies requiring near real-time clinical decision-making.
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Monitor and ensure timely and accurate completion of key quality activities involving clinical decision-making.
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Write narrative reports interpreting regulatory specifications and documenting findings.
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Lead quality improvement activities, meetings, and discussions with other departments.
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Perform lead role in coordination and preparation of the HEDIS medical record review.
Requirements
Bachelor's degree in nursing or higher.
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Minimum 3 years' experience in healthcare with at least 2 years' experience in health plan quality improvement or managed care.
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Active and unrestricted RN license for the State(s) of employment.
Nice-to-haves
Master's degree in nursing or higher.
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2 years coding and medical record abstraction experience.
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1 year managed care experience.
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Basic knowledge of HEDIS and NCQA.
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Certified Professional in Health Quality (CPHQ).
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Certified HEDIS Compliance Auditor (CHCA).
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Registered Health Information Technician (RHIT) or Certified Medical Record Technician with training in coding procedures.
Benefits
Medical, Dental, and Vision Insurance
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Group & Voluntary Life Insurance
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Aflac, Pet Health, and Identity Theft Insurance
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Flexible Spending Accounts
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401K and Roth 401K
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Employee Stock Purchase Plan
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Continuing Education Units
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Education Reimbursement
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Paid Time Off
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Volunteer Time Off
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Company Holidays
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Legal Assistance Plan
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Employee Assistance & Well Being Programs
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Employee Perks Platform
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Rideshare Portal
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