Quality Improvement Specialist

Monitors and investigates all quality of care concerns and collaborates with medical director to determine impact and next steps for actions. Monitors provider quality complaints to identify trends and educational opportunities for improvement. Monitors quality improvement initiatives including, but not limited to, development and implementation of preventive health and chronic disease outcome improvement interventions such as: newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys. Analyzes, updates, and modifies procedures and processes to continually improve QI operations. Collects and summarizes performance data and identifies opportunities for improvement. Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met. Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA, EQRO). Conducts internal auditing of compliance with regulatory and accreditation standards. Pursues methods to ensure receipt of data required for trending and reporting of various QI work plan metrics, performs adequate data/barrier analysis, develops improvement recommendations, and deploys actions as approved. Participates in various QI committees and work groups convened to improve process and/or health outcomes, and contributes meaningful detail, based on functional knowledge. Completes follow-up as assigned. Manages and monitors assigned quality studies. Investigates and incorporates national best practice interventions to affect greater rate increases. Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements. Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline. Performs other duties as assigned. Additional Responsibilities: Completes Licensed Health Care Risk Management certification program. Performs annual update on Plan Risk Management Program Description. Coordinates the regular and systematic review of all potential adverse incidents in accordance with state statute. Complete Performs other duties as assigned. Complies with all policies and standards. Position Purpose Monitors and investigates all quality of care concerns and collaborates with medical director to determine impact and next steps for actions. Monitors provider quality complaints to identify trends and educational opportunities for improvement. Monitors quality improvement initiatives including, but not limited to, development and implementation of preventive health and chronic disease outcome improvement interventions such as: newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys. Analyzes, updates, and modifies procedures and processes to continually improve QI operations. Collects and summarizes performance data and identifies opportunities for improvement. Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met. Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA, EQRO). Conducts internal auditing of compliance with regulatory and accreditation standards. Pursues methods to ensure receipt of data required for trending and reporting of various QI work plan metrics, performs adequate data/barrier analysis, develops improvement recommendations, and deploys actions as approved. Participates in various QI committees and work groups convened to improve process and/or health outcomes, and contributes meaningful detail, based on functional knowledge. Completes follow-up as assigned. Manages and monitors assigned quality studies. Investigates and incorporates national best practice interventions to affect greater rate increases. Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements. Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline. Performs other duties as assigned. Additional Responsibilities: Completes Licensed Health Care Risk Management certification program. Performs annual update on Plan Risk Management Program Description. Coordinates the regular and systematic review of all potential adverse incidents in accordance with state statute. Complete Performs other duties as assigned. Complies with all policies and standards. Supports the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies impacting plan compliance to regulatory and accreditation standards. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytics and reporting activities. Licenses and Certifications: A license in one of the following is required: Required Licensed Registered Nurse (RN) Education/Experience A High School or GED with a current unrestricted RN license Required/Preferred: Required A Bachelor's Degree in Healthcare, Nursing, Health Administration, Public Health or related health field: Required/Preferred: Preferred Work Experience: 2+ years of experience in Quality Improvement Required/Preferred: Required 3+ years of experience in Managed Care, Preferred. Other Experience In Compliance And Accreditation Required/Preferred: Required Other Knowledge Of Federal And State Regulations/requirements Required/Preferred: Required For Ohana Health Plan only: Associates Degree required; must be a Licensed RN in the state of Hawaii. Pay Range: $56,200.00 - $101,000.00 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 #J-18808-Ljbffr