QI Specialist II

Quality Improvement Specialist

Will this role be fully remote? Yes, but may require on-site visits to a provider's office to retrieve medical records. Must reside in FL (preferably in Miami, FL). Expected schedule: M-F, 8-5, Eastern.

Some must-have requirements for a Quality Improvement Specialist supporting the Medicare RDAV project include a strong understanding of Medicare risk adjustment, including familiarity with CMS RADV/RDAV processes, HCC coding, and medical record documentation standards. Candidates should have experience in healthcare quality improvement, audit support, or chart review, with the ability to interpret clinical documentation and identify coding gaps. Proficiency in data analysis, reporting tools, and Excel is important for tracking performance and validating data. Strong attention to detail, organizational skills, and the ability to manage multiple deadlines are essential, along with effective communication skills to collaborate with providers and cross-functional teams. A bachelor's degree in a healthcare-related field is typically required, and certifications such as CPC, CRC, or CPHQ are highly preferred.

The Quality Improvement (QI) Specialist supporting the Medicare RDAV project is responsible for the day-to-day coordination, monitoring, and execution of activities that drive accurate and timely risk adjustment data validation. This includes reviewing and validating medical record documentation, collaborating with providers and internal teams to resolve data discrepancies, supporting chart retrieval and submission processes, and ensuring compliance with CMS RDAV requirements. The specialist analyzes performance trends, identifies gaps in coding and documentation, and helps implement targeted interventions to improve data accuracy and audit readiness. Additionally, they maintain tracking tools, support reporting needs, and communicate progress, risks, and outcomes to leadership to ensure successful project execution and regulatory compliance.

Summary: Responsible for developing, organizing, collecting, coordinating, preparing and presenting results of quality improvement studies and projects activities to monitor, evaluate and continuously improve the quality of healthcare services provided to Molina member. Essential functions include collaborating with the Quality Improvement department staff in the development of quality improvement studies, initiatives and projects to improve the health care of members, planning and coordinating the collection, evaluation and dissemination of quality improvement data for quality initiatives, studies and projects to comply with regulatory requirements and accreditation standards, preparing reports and analyses to evaluate performance with standards from a variety of sources, performing qualitative and quantitative analysis to identify significant and problematic clinical issues and concerns, development of improvement plans and measurement to assess impact of actions, participating in NCQA accreditation and regulatory audit preparedness and maintaining activities including preparing reports, narratives, graphs, charts, etc. as needed for external audits and surveys, participating in and facilitating quality improvement program committees, as assigned, including preparing materials, minutes and tracking action items for committee review, developing and maintaining Quality Improvement department policies and procedures, materials and reports in accordance with State, Federal, and NCQA and Molina requirements, performing audits of materials and medical records to demonstrate compliance with contractual obligations, identify opportunities for improvement, and to validate medical record-keeping practices for credentialing and recredentialing purposes, collecting HEDIS data and/or Ambulatory Medical Record Review Data through chart review of medical records (medical record abstraction) as directed, supporting various HEDIS activities as needed, reviewing, identifying and trending quality of care issues, serious reportable adverse conditions and assisting in the implementation of corrective action plans, participating in the development of materials as needed for member and provider quality initiatives such as HEDIS, improvement projects, and studies.

Knowledge/Skills/Abilities: Proficiency with PC-based systems, excellent verbal and written communication skills, ability to abide by Molina's policies, ability to maintain attendance to support required quality and quantity of work, maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA), ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Required Education: Bachelor's Degree in Public Health or related healthcare field (equivalent experience in lieu of a Bachelors). Required Experience: 2-4 years experience in Quality Improvement. 2-4 years experience in managed care or healthcare industry. Experience with qualitative or quantitative projects/analysis. Required Licensure/Certification: May require an RN/LPN for some State Plans.