QI Specialist II

Quality Improvement Specialist

This role is fully remote but may require on-site visits to a provider's office to retrieve medical records. Candidates must reside in Florida, preferably in Miami, FL. The expected schedule is Monday through Friday, 8 AM to 5 PM, Eastern Time Zone.

Top skills required include a strong understanding of Medicare risk adjustment, 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 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 members. 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; participating in NCQA accreditation and regulatory audit preparedness; participating in and facilitating quality improvement program committees; developing and maintaining Quality Improvement department policies and procedures; performing audits of materials and medical records; collecting HEDIS data and/or Ambulatory Medical Record Review Data through chart review of medical records; supporting various HEDIS activities; reviewing, identifying, and trending quality of care issues; participating in the development of materials for member and provider quality initiatives; and maintaining proficiency with PC-based systems, excellent verbal and written communication skills, ability to abide by Molina's policies, ability to maintain attendance, maintain confidentiality, comply with HIPAA, and establish and maintain positive and effective work relationships.