Senior Specialist, Health Plan Quality Program Management & Performance (RN) - Remote

Molina Healthcare•Long Beach, CA

5d•Remote

About The Position

Provides senior-level clinical support to the quality team by contributing to quality management programs, initiatives, audits, data analysis, quality improvement surveys, and state and federal quality compliance activities. Contributes to the overarching strategy of providing safe, efficient, and cost-effective member care. The role performs and monitors quality investigations and audits, tracks reportable incidents and other quality concerns, and ensures that clinical quality activities are completed accurately and on time. It implements quality strategies involving near-real-time clinical decision-making, supports the creation and revision of quality policies and procedures, and evaluates program activities to identify improvement opportunities and process gaps.

Requirements

At least 3 years of healthcare experience, including at least 1 year of quality management and clinical quality investigations experience, preferably in managed care, or equivalent experience.
Active, unrestricted Registered Nurse license in the state of practice.
Some states may require 1 year of behavioral health experience, depending on state or contractual requirements.
Experience in quality auditing, peer review, and process improvement.
Knowledge of HEDIS (Healthcare Effectiveness Data and Information Set) and NCQA (National Committee for Quality Assurance).
Strong attention to detail, critical-thinking, and problem-solving skills.
Ability to work cross-collaboratively in a highly matrixed organization.
Time-management skills and ability to multitask.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office suite and applicable software programs.

Nice To Haves

Certified Professional in Health Quality (CPHQ).
Medical-record abstraction experience.
Managed-care experience.
Ability to work across all organizational levels, including with executive audiences, vendors, providers, and government customers.

Responsibilities

Conduct individual and systemic quality-of-care investigations in a timely, accurate manner and in accordance with state-based requirements.
Track and trend reportable incidents, quality-of-care events, member service concerns, and mortalities in accordance with established structures and processes.
Perform quality monitoring, including audits of medical-record quality, services and service sites, health and safety, and follow-up monitoring of placement settings.
Monitor clinical quality activities to ensure timely and accurate completion, and present results to departmental leadership and other departments as needed.
Implement quality strategies requiring near-real-time clinical decision-making, including managing interventions to improve patient safety; preparing and reviewing potential quality-of-care and critical-incident cases; reviewing medical-record documentation for credentialing and model-of-care oversight; and carrying out other federally and state-required quality activities.
Follow written documentation and business practices, including policies, procedures, manuals, desk-level procedures, and process flows.
Support the creation and ongoing revision of policies and procedures for quality management functions, including audits, credentialing and recredentialing, quality-of-care concerns, and peer review.
Apply knowledge of quality management program requirements and day-to-day processes to support compliance with state contracts, policies, and program requirements.
Evaluate project and program activities and results to identify improvement opportunities.
Escalate process gaps that may require remediation to appropriate leadership and contribute a clinical perspective to identifying process gaps or limitations.