Specialist, Health Plan Quality Program Mgmt & Performance (Remote in WI)

JOB DESCRIPTION Job Summary

Provides support for quality management and quality performance improvement activities. Responsible for overseeing, planning, and implementing new and existing health plan quality improvement activities to maintain compliance with quality program requirements and reporting and monitoring for key quality program activities, and provides support and implementation of National Committee for Quality Assurance (NCQA) accreditation surveys and federal/state quality improvement compliance activities, including compliance with Healthcare Effectiveness Data and Information Set (HEDIS) regulations.

Essential Job Duties

• Conducts quality program management activities in compliance with state, federal, and National Committee for Quality Assurance (NCQA) regulatory requirements.
  • Monitors and ensures that key quality activities are completed on time and accurately, and presents results to key departmental leaders and stakeholders to meet regulatory requirements.
  • Writes (and/or reviews) narrative reports to interpret regulatory specifications, explains programs and results of programs, and documents findings and limitations of department interventions.
  • Supports projects, programs, and initiatives within the quality department.
  • Creates, manages, and/or compiles the required documentation to maintain critical quality improvement functions.
  • Participates in quality improvement activities, meetings, and discussions with other cross-functional departments within the organization to ensure quality programs meet regulatory requirements.
  • Raises gaps in quality processes that may require remediation to quality leadership.
  • Facilitates individual and systemic quality of care investigations.
  • Monitors and evaluates the structure and processes for tracking and trending reportable incidents, quality of care events, member service concerns, and mortalities.
  • Organizes and manages quality monitoring activities, including audits of medical record quality, services and service sites, health and safety, and follow-up of monitoring of placement settings.
  • Creates, manages, and leads quality management activities, meetings, and discussions with and between other departments within the organization.
  • Evaluates project/program activities and results to identify opportunities for improvement.
  • Monitors and collaborates with quality leadership to address any gaps in processes that may require remediation.
  • Creates and implements written documentation and business practices (e.g., policies and procedures, desk-level procedures, manuals, and process flows) that explain the business requirements and how the unit operationalizes those requirements.
  • Maintains the creation and ongoing revision of policies and procedures reflective of state requirements for all quality management functions, including quality monitoring audits, credentialing and recredentialing, quality of care concerns, and peer review.
  • Maintains knowledge necessary to be well-versed in the requirements of the quality management program and day-to-day work processes to support compliance with state contract, policies, and program requirements.
  • Same-day out-of-office travel approximately 0-25% of the time may be required, depending on health plan/state-specific needs.
  • Multi-day out of town overnight travel approximately 0-10% of the time may be required, depending upon health plan/state-specific needs.

Required Qualifications

• At least 2 years of experience in health care, with at least 1 year of experience in health plan quality improvement, or equivalent combination of relevant education and experience.
  • Basic knowledge and understanding of HEDIS/NCQA.

• Business writing experience.

• Data analysis, manipulation, interpretation and reporting skills.
  • Critical-thinking, problem-solving and analytical skills.
  • Attention to detail and organizational skills.
  • Ability to work independently in a fast-paced, deadline-driven environment.
  • Effective verbal and written communication skills.
  • Microsoft Office suite (including Excel), and applicable software programs proficiency, and ability to learn new information systems and software programs.

Preferred Qualifications

• Experience with government-sponsored programs (Medicaid, Medicare, Marketplace).
  • Certified Professional in Health Quality (CPHQ).
  • Registered Nurse (RN). If licensed, license must be active and unrestricted in state of practice.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Originally posted on Himalayas