Sr Specialist, Quality Improvement (RN) - Remote at Molina Healthcare

About the position

Molina's Quality Improvement function is dedicated to overseeing, planning, and implementing both new and existing healthcare quality improvement initiatives and education programs. This role ensures the maintenance of programs for members in accordance with prescribed quality standards. The Senior Specialist, Quality Improvement (Registered Nurse) plays a crucial role in conducting data collection, reporting, and monitoring for key performance measurement activities. Additionally, this position provides direction and implementation of NCQA accreditation surveys and federal/state quality improvement compliance activities. In this capacity, the Senior Specialist contributes to various quality improvement functions, including Quality Interventions, Quality Improvement Compliance, HEDIS, and Quality Reporting. Acting 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 role involves implementing key quality strategies that necessitate near real-time clinical decision-making, which may include 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 responsible for monitoring and ensuring that key quality activities involving clinical decision-making are completed accurately and on time, presenting results to departmental management and other Molina departments as necessary. This position also entails writing narrative reports to interpret regulatory specifications, explain programs and results, and document findings and limitations of department interventions. Furthermore, the Senior Specialist leads quality improvement activities, meetings, and discussions with other departments, surfacing any process gaps to management that may require remediation, particularly where a clinician's perspective is valuable. In terms of HEDIS and Quality Reporting, the Senior Specialist coordinates and prepares the HEDIS medical record review, which includes ongoing reviews of records submitted by providers and the annual HEDIS medical record review. This role requires clinical decision-making and involves participation in meetings with vendors for the medical record collection process. The Senior Specialist collects medical records, loads data into the HEDIS application, and ensures that preventive and diagnostic services have been correctly performed according to specifications. Additionally, the role supports quality improvement studies and performance improvement projects, assisting with accreditation activities such as NCQA reviews and state audits by reviewing clinical documentation.

Responsibilities
• Oversee and implement healthcare quality improvement initiatives and education programs.
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• Conduct data collection, reporting, and monitoring for key performance measurement activities.
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• Provide direction and 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 completion of key quality activities involving clinical decision-making.
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• Write narrative reports interpreting regulatory specifications and documenting findings of department interventions.
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• Lead quality improvement activities, meetings, and discussions with other departments.
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• Coordinate and prepare the HEDIS medical record review, including ongoing reviews of records submitted by providers.
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• Collect medical records and load data into the HEDIS application, ensuring compliance with specifications.

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 Clinical Quality, Public Health, or Healthcare.
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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
• Competitive benefits and compensation package.

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