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HEDIS Operations experience highly preferred
Clinical Medical Record Review experience.
Position Purpose: The Senior Quality Improvement Specialist is responsible for coordinating assigned regulatory, accreditation, clinical quality and/or service improvement programs. Functions as a leader for assigned health services initiatives handling multiple large-scale complex initiatives. Collaborates on national, regional and multi-plan initiatives. Develops programs in compliance with accreditation and regulatory requirements/ standards and monitors ongoing program performance to maintain compliance. Acts as a resource for training, policy and regulatory/accreditation interpretation.
Leads and manages multiple complex initiatives that impact the quality or effectiveness of health care delivery and/or health care services provided to members.
Ensures that clinical and service quality improvement programs and initiatives are compliant with applicable accreditation, state and federal requirements.
Conducts an assessment of programs, initiatives and interventions to ensure goals and objectives were met and refine activities, as needed, to improve the effectiveness and improve outcomes.
Conducts vendor oversight and management.
Develops targeted activities to improve Star Ratings, HEDIS, CAHPS, HOS, provider satisfaction and other identified performance measures.
Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas.
Participates in the development and maintenance of annual quality improvement program documents and evaluations, compliance audits, policies and procedures, and improvement activities.
Develops internal reports to demonstrate progress on each initiative/project and presents to senior-level staff.
Describes outreach initiatives, potential/experienced barriers and activities to resolve issues and improve outcomes.
Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management.
Identifies areas of improvement within the company and works collaboratively with other departments to develop clinical and non-clinical performance improvement projects.
Researches best practices, national and regional benchmarks, and industry standards.
Develops collaborative relationships with contracted providers or provider groups to promote participation in quality improvement collaboratives to improve clinical care outcomes.
May lead and/or participate in external activities, work groups or committees when applicable.
Communicates programs, interventions and results to external entities in accordance with applicable program objectives, policies and procedures.
Develops and/or maintains relationships with other external organizations to expand key partnerships.
Assesses current industry trends and regulations for enterprise-wide adoption to assure quality and effectiveness of health care delivery and/or healthcare services provided to members.
Performs all other duties as assigned.
Performs other duties as assigned
Complies with all policies and standards
Education/Experience:
Education: Bachelor’s Degree or equivalent experience with clinical license or Master’s Degree in related health field (i.e. MPH or MPA) Certification/License: Valid state clinical license preferred Certified Professional in Health Care Quality (CPHQ) preferred.
Experience: Minimum three years experience in a clinical/health care environment with related degree program Three to five years managed care experience in a health care environment Experience in compliance, accreditation, service or quality improvement Complex project management experience Experience with Medicare and/or NCQA preferred: Pay Range: $70,100.00 - $126,200.00 per year
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
