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

Molina Healthcare•Long Beach, WA

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 for safe, efficient, and cost-effective member care. The role supports quality investigations and monitoring, clinical decision-making, compliance with state contracts and program requirements, and continuous process improvement.

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 Healthcare Effectiveness Data and Information Set (HEDIS) and National Committee for Quality Assurance (NCQA).
Strong attention to detail, critical-thinking, and problem-solving skills.
Ability to work collaboratively across 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 accurately, promptly, and in accordance with state requirements.
Track and trend reportable incidents, quality-of-care events, member service concerns, and mortalities according to established 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 interventions to improve patient safety; preparation and review of potential quality-of-care and critical incident cases; medical record documentation review for credentialing and model-of-care oversight; and other federally or state-required quality activities.
Follow written documentation and business practices, including policies, procedures, desk-level procedures, manuals, and process flows.
Support the creation and revision of policies and procedures reflecting state requirements for quality monitoring audits, credentialing and recredentialing, quality-of-care concerns, and peer review.
Apply knowledge of quality management program requirements and daily work 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 clinician's perspective to identifying process gaps or limitations.