Associate Quality Practice Advisor

Centene Management Company LLC; Pennsylvania; Hybrid; USD 77,479,000 - 139,116,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off + holidays

Flexible work options

Job summary

Centene in Pennsylvania seeks a Quality Improvement Specialist to educate providers on NCQA HEDIS measures, improve medical record documentation, and ensure proper coding aligned with state and federal standards.

You will travel up to 75% within Southeast Pennsylvania, collect performance data, and collaborate with Provider Relations to drive provider performance and member wellness.

Qualifications

• Bachelor's degree in a healthcare-related field is required or equivalent experience in HEDIS review/quality improvement.
• Master's degree preferred.
• Experience with data and chart reviews to provide education to providers is expected.

Responsibilities

• Educates providers on HEDIS measures and NCQA coding guidelines.
• Collects and trends provider performance data to identify improvement opportunities.
• Collaborates with Provider Relations to improve Quality, Risk Adjustment, and Operations.
• Coaches providers on gap closure and action plans; documents outcomes.

Skills

HEDIS knowledge

Provider education

Data analysis

Quality improvement

Travel up to 75%

Education

Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field

Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field

Job description

Eligibility

Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

Position Purpose

Establishes and fosters a healthy working relationship between community physician and small provider practices and WellCare. Educates providers and supports provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures. Provides education for HEDIS measures, appropriate medical record documentation and appropriate coding. Assists in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS.

Key Details

Must have reliable transportation and a valid drivers' license. Must live in the Southeast Pennsylvania area and be willing to travel up to 75% of the time.

• Under general guidance from Senior Quality Practice Advisors and management, educates community physician and small provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements.


• Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement.


• Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).


• Assists in delivering provider specific metrics and coaches providers on gap closing opportunities.


• Assists in identifying specific practice needs where WellCare can provide support.


• Partners with physicians/physician staff to find ways to encourage member clinical participation in wellness and education.


• Provides resources and educational opportunities to provider and staff.


• Captures concerns and issues in action plans as agreed upon with provider.


• Documents action plans and details of visits and outcomes.


• Reports critical incidents and information regarding quality of care issues.


• Communicates with external data sources as needed to gather data necessary to measure identified outcomes.


• Provides communication such as newsletter articles, member education, outreach interventions and provider education.


• Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.


• 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.


• Enter documentation of findings in identified databases and ensure accuracy in medical records for data collection, DE and reporting.


• Performs other duties as assigned.


• Complies with all policies and standards.

Education / Experience

A bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field or equivalent work experience within a managed care environment related to HEDIS record review, quality improvement, medical coding or transferable skill sets that demonstrates the ability to perform the role is required. A Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field is preferred.

1+ year of experience in related HEDIS medical record review or quality improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff OR 2 years medical coding or other transferable experience and skill set combination that demonstrates the ability to learn and perform the level of the position.

A license in one of the following is preferred:

• Certified Coding Specialist (CCS)


• Licensed Practical Nurse (LPN)


• Licensed Master Social Work (LMSW)


• Licensed Vocational Nurse (LVN)


• Licensed Mental Health Counselor (LMHC)


• Licensed Marital and Family Therapist (LMFT)


• Licensed Certified Social Worker (LCSW)


• Licensed Registered Nurse (RN)


• Acute Care Nurse Practitioner (APRN) (ACNP-BC)


• Other Foreign trained physician/MD


• Health Care Quality and Management (HCQM)


• Certified Healthcare Professional (CHP)


• Certified Professional in Healthcare Quality (CPHQ)

Pay Range

Pay Range: $27.02 - $48.55 per hour

About Centene

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.

Benefits

• competitive pay


• health insurance


• 401K and stock purchase plans


• tuition reimbursement


• paid time off plus holidays


• 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.

Equal Opportunity Employer

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.

Contact

Should you need an accommodation, please email [e-mail]. Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.