Molina Healthcare is hiring Nursing professionals for their Potential of Quality of Care team (PQOC).
* Candidates with prior experience working with Utilization Review, Concurrent Review, Appeals & Denials, Clinical Investigations and Case Management are highly desirable.
* Candidates with Clinical Hospital setting, Managed Care or Home Health experience are highly desirable.
* Experience working with all types of populations, NICU, PICU or ICU settings are highly desirable.
Molina's Quality Improvement function oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities.
The Senior Specialist, Quality Improvement (Registered Nurse) contributes to one or more of these quality improvement functions: Quality Interventions, Quality Improvement Compliance, HEDIS, and / or Quality Reporting.
Quality Intervention / QI Compliance
Acts as a lead specialist to provide project-, program-, and / or initiative-related direction and guidance for other specialists within the department and/or collaboratively with other departments.
Implements key quality strategies that require a component of near real-time clinical decision-making. These activities may include initiation and management of interventions (e.g., removing barriers to care); preparation for Quality Improvement Compliance surveys; preparation and review of potential quality of care and critical incident cases; review of medical record documentation for credentialing and model of care oversight; and any other federal and state required quality activities.
Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately in order to present results to key departmental management and other Molina departments as needed.
Writes narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions.
Creates, manages, and/or compiles the required documentation to maintain critical quality improvement functions that have a component of clinical decision-making.
Leads quality improvement activities, meetings and discussions with and between other departments within the organization. Often the Senior Specialist will be assigned activities where clinical expertise is important to the activity.
Surfaces to Manager and Director any gaps in processes that may require remediation. In particular, the Senior Specialist may be asked to focus on parts of the process where a clinician's perspective would be valuable to uncover process gaps or limitations.
HEDIS / Quality Reporting
Performs the lead role in the coordination and preparation of the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review. The Senior Specialist will be asked to perform duties where clinical decision-making may be necessary.
Participates in meetings with vendors for the medical record collection process.
Assists Manager and Supervisor(s) in training and takes the lead role in these activities
Collects medical records and reports from provider offices, loads data into the HEDIS application, and compares the documentation in the medical record to specifications to determine if preventive and diagnostic services have been correctly performed.
Works with the corporate HEDIS team to monitor accuracy of abstracted records as required by specifications.
Participates in scheduled meetings with the corporate HEDIS team, vendors and HEDIS auditors.
Assists the quality improvement staff with physician and member interventions and incentive efforts as needed through review of medical records documentation.
Provides data collection and report development support for quality improvement studies and performance improvement projects.
Assists as needed in support of accreditation activities such as NCQA reviews, CAHPS and state audits by reviewing clinical documentation.
Bachelor's degree in nursing or higher
Min. 3 years experience in healthcare with minimum 2 years experience in health plan quality improvement, managed care or equivalent experience.
Required License, Certification, Association
Active RN license for the State(s) of employment
Preferred field: Clinical Quality, Public Health or Healthcare. Nursing: Master's or higher
2 years coding and medical record abstraction experience.
1 year managed care experience.
Basic knowledge of HEDIS and NCQA.
Preferred License, Certification, Association
Certified Professional in Health Quality (CPHQ)
Certified HEDIS Compliance Auditor (CHCA)
Registered Health Information Technician (RHIT), or
Certified Medical Record Technician with training in coding procedures (as required by state/location only), or
Certified Professional Coder (CPC)
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job: **Quality Assurance*
Title: Sr Specialist, Quality Improvement (RN) - PQOC (Remote - Mid-West, West Coast Region)
Location: CA-Long Beach-Remote Employees
Requisition ID: 1903273
Other Locations: US-CA-San Diego-SDSKY, US-TX-Richardson-UNITAS, US-TX-Plano-TXPLA, US-CA-Hagginwood-KSTREET, US-CA-Long Beach-MOLINA300, US-CA-Sacramento-SACRAMENT, US-IL-Champaign-CHAMPVO, US-IL-Oak Brook-OAKBROOK, US-IL-East Saint Louis-ESTLVO, US-CA-Sacramento-HARVSAC, US-CA-East Compton-CACOMP2, US-TX-San Antonio-TXBEXAR, US-CA-San Bernardino-SANBNRDO, US-CA-Long Beach-MOLINA100, US-CA-Corona-CACORMAIN, US-CA-Long Beach-HUGHES, US-UT-West Valley City-SLCCL, US-CA-Long Beach-UNION, US-IL-Chicago-ILCHI, US-IL-Peoria-PEORVO, US-IL-Bloomington-BLOOMVO, US-TX-Houston-TXHARRIS, US-CA-Long Beach-MEEKER, US-WA-Wenatchee-WENAT, US-TX-Irving-TXWESTRIDG, US-CA-Long Beach-CONVERSION, US-CA-El Centro-CAELC, US-WI-Milwaukee-WATERS, US-UT-Midvale-UTAH, US-CA-San Pedro-CASANP, US-IL-Centreville-CENTREVO, US-UT-Orem-OREM, US-TX-El Paso-TXELP, US-CA-Sacramento-NORWOORD, US-NM-Las Cruces-JNMLCR, US-WA-Bothell-BOTHELL, US-IL-Danville-DANVILLEVO, US-NM-Albuquerque-NMALBT, US-TX-Irving-TXIRV, US-WA-Everett-EVERETTMA, US-CA-Lancaster-LANCASTER, US-WA-Spokane-SPOKANE, US-IL-Galesburg-GALESVO, US-IL-Springfield-SPRINGFIEL, US-CA-Victorville-CAVIC, US-CA-San Bernardino-CASAN, US-CA-Long Beach-MOLINA200, US-WA-Vancouver-WAVAN, US-CA-Pomona-SECONDST, US-TX-Edinburg-TXEDI, US-CA-Long Beach-LB6TH, US-IL-Lake Forest-LAKEFRVO, US-TX-Laredo-TXLAREDO, US-CA-Rancho Mirage-PALMDES