Quality Improvement Specialist (HEDIS) II

Centene Corporation•Remote-MO, MO

2d•$70,100 - $126,200•Remote

About The Position

This role takes a lead role in the development and maintenance of quality improvement related projects specific to HEDIS Hybrid Operations. The position serves as the primary owner for assigned HEDIS measures and leads complex quality improvement initiatives to support the health plans. Applicants for this job have the flexibility to work remote from home anywhere in the United States. The role involves training providers, health plans, and staff in continuous quality improvement methodologies and HEDIS abstraction processes, providing clinical support for medical record abstraction, over-read, and audit processes, and monitoring performance on contractual quality indicators. The specialist will analyze, track, and trend results, prepare for and participate in meetings with various stakeholders, and recommend, develop, and implement quality performance improvement plans (PIPs) using the PDSA model. This position also involves monitoring and reporting PIP progress, serving as the primary owner for assigned HEDIS measures (including year-round performance, gap identification, and intervention planning), and supporting department leadership in project and strategy development. The role leads quality improvement initiatives for complex or high-risk HEDIS measures with market-wide impact, provides functional and technical knowledge regarding program requirements, and offers guidance on complex abstraction scenarios, team training, and measure interpretation. The specialist demonstrates advanced proficiency in clinical medical record abstraction and serves as a mentor to team members. Other duties as assigned and compliance with all policies and standards are also required.

Requirements

Bachelor’s degree in Nursing, Healthcare, or Quality (including HEDIS measures or NCQA) or equivalent experience in related healthcare experience.
Requires 2+ years of experience in Quality.
Knowledge of HEDIS & performance measures strongly preferred.
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J -1, OPT, or CPT.

Responsibilities

Train providers, health plans and staff in methodologies and tools of continuous quality improvement and HEDIS abstraction and over-read processes.
Provide clinical support to the medical record abstraction, over-read and audit processes.
Monitor performance on established contractual quality indicators.
Analyze, track and trend results.
Prepare for and participate in meetings with various committees, state agencies, providers, health plans, vendors, and stakeholders.
Recommend, develop, and implement quality performance improvement plans (PIPs) with management utilizing the PDSA model.
Monitor and report PIPs progress through closure.
Serve as primary owner for assigned HEDIS measures, including year-round pseudo-claims performance, gap identification, and intervention and strategy planning.
Support department leadership in project and strategy development; Lead quality improvement initiatives involving complex or high-risk HEDIS measures with market-wide impact.
Provide functional and technical knowledge regarding overall program requirements and operations.
Provide guidance on complex abstraction scenarios, team training, and measure interpretation using critical clinical abstraction knowledge.
Demonstrate advanced proficiency across all phases of clinical medical record abstraction, including data entry, over read, and inter-rater reliability (IRR/third level over read), while serving as a mentor and resource to team members by providing guidance on measure interpretation, abstraction standards, and quality improvement best practices.
Perform other duties as assigned.
Comply with all policies and standards.