Quality Improvement Coordinator II

Centene Corporation

1d•$34 - $61•Remote

About The Position

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits. Perform community activities related to clinical initiatives such as health fairs and communicate with agencies and providers. Perform quality on site reviews of delegated entities, physician office/clinics, resolve quality issues, generate written summary of findings and follow up as directed by the Medical Director and/or Credentialing and Quality Improvement Committee (QIC). Document, investigate and resolve formal and informal complaints, risk management and sentinel events related to quality of care issues. Audit medical records, review administrative claims and analyze data and interventions for quality improvement studies and activities Function as the primary liaison between community resources/agencies and the company related to clinical initiatives and technical guidance. Schedule and chair meetings with delegated entities in accordance with their contract. Gather data and compile various utilization and quality improvement reports. Develop and implement Corrective Action Plans. Recommend changes/enhancements to the Quality Improvement policies and procedures. Identify best practices, research new processes and recommend program enhancements. Coordinate QIC activities and monthly meetings. Oversee the enforcement of contract terms regarding data submission for delegated entities. Participate in the development of reporting and data outcome reports. Performs other duties as assigned Complies with all policies and standards This is a fully remote position; candidates must be able to work within the Central Time Zone. The ideal candidate will have prior experience conducting high‑volume phone outreach to members or providers, strong communication and presentation skills, and prior HEDIS experience.

Requirements

Bachelor’s degree in Nursing preferred.
3+ years of clinical, quality improvement or healthcare experience.
2+ years of experience in quality function in a healthcare setting.
LPN, LVN, RN, PA, or LCSW license preferred.

Nice To Haves

CPHQ (Certified Professional in Healthcare Quality) preferred.
The ideal candidate will have prior experience conducting high‑volume phone outreach to members or providers, strong communication and presentation skills, and prior HEDIS experience.

Responsibilities

Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits.
Perform community activities related to clinical initiatives such as health fairs and communicate with agencies and providers.
Perform quality on site reviews of delegated entities, physician office/clinics, resolve quality issues, generate written summary of findings and follow up as directed by the Medical Director and/or Credentialing and Quality Improvement Committee (QIC).
Document, investigate and resolve formal and informal complaints, risk management and sentinel events related to quality of care issues.
Audit medical records, review administrative claims and analyze data and interventions for quality improvement studies and activities
Function as the primary liaison between community resources/agencies and the company related to clinical initiatives and technical guidance.
Schedule and chair meetings with delegated entities in accordance with their contract.
Gather data and compile various utilization and quality improvement reports.
Develop and implement Corrective Action Plans.
Recommend changes/enhancements to the Quality Improvement policies and procedures.
Identify best practices, research new processes and recommend program enhancements.
Coordinate QIC activities and monthly meetings.
Oversee the enforcement of contract terms regarding data submission for delegated entities.
Participate in the development of reporting and data outcome reports.
Performs other duties as assigned
Complies with all policies and standards