Senior Specialist, Health Plan Quality Program Management & Performance (RN) - Remote

Molina Healthcare; Seattle (WA); Remote; USD 83,000 - 135,000; Full time

Job summary

Molina Healthcare is seeking a senior clinical quality professional to support quality management programs, audits, data analysis, and improvement initiatives. The role emphasizes outbound outreach to members and providers and ensures compliance with state quality standards.

The position focuses on safety, efficiency, and cost-effective member care, requiring strong collaboration across departments and the ability to apply clinical judgment in near real-time decisions.

Qualifications

• At least 3 years in health care with 1 year in quality management or clinical quality investigations.
• Knowledge of HEDIS/NCQA is a plus.
• Experience in a managed care setting is preferred.

Responsibilities

• Perform quality investigations and ensure compliance with state requirements.
• Track and trend reportable incidents and quality events.
• Conduct quality monitoring audits of medical records and services.
• Present results to leadership and applicable departments.
• Contribute to policy/procedure development reflecting state requirements.

Skills

Attention to detail

Strong communication skills

Critical thinking

Problem solving

Time management

Cross-functional collaboration

Education

RN license (active)

CPHQ preferred

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary Provides senior level clinical support to quality team - contributing to quality management programs, initiatives, audits, data analysis and quality improvement surveys and state/federal quality compliance activities. Contributes to overarching strategy to provide safe, efficient and cost-effective member care.

This remote position is primarily focused on making outbound calls to members and/or providers regarding health, wellness or prevention information.

Essential Job Duties

• Ensures individual and systemic quality of care investigations are performed timely, accurately, and in accordance with state-based requirements.
• Adheres to structure and processes for tracking and trending reportable incidents, quality of care events, member service concerns, and mortalities.
• Performs quality monitoring activities, including audits of medical record quality, services and service sites, health and safety, and follow-up monitoring of placement settings.
• Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately; presents results to key departmental leadership and other departments as needed.
• Implements key quality strategies that require a component of near real-time clinical decision-making. These activities may include initiation and management of interventions (e.g., improving patient safety); preparation and review of potential quality of care and critical incident cases; review of medical record documentation for credentialing and model of care oversight; and any other federal and state required quality activities.
• Adheres to written documentation and business practices (e.g., policies and procedures, desk-level procedures, manuals, and process flows) that explain business requirements and how the unit operationalizes those requirements.
• Supports 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.
• Demonstrates understanding of requirements of the quality management program and day-to-day work processes to support compliance with state contract, policies, and program requirements.
• Evaluates project/program activities and results to identify opportunities for improvement.
• Raises any gaps in processes that may require remediation to appropriate leadership; may be asked to focus on parts of a process where a clinician's perspective would be valuable to uncover process gaps or limitations.

Required Qualifications

• At least 3 years experience in health care, with a minimum of 1 year of experience in quality management and clinical quality investigations, preferably in a managed care setting, or equivalent experience
• Registered Nurse. License must be active and unrestricted in state of practice.
• Some states may require 1 year of behavioral health experience (depends on state/contractual requirements).
• Quality auditing, peer review, and process improvement experience.
• Knowledge of Healthcare Effectiveness Data Information Set (HEDIS) and National Committee for Quality Assurance (NCQA).
• Strong attention to detail, critical-thinking, and problem solving skills.
• Ability to work cross-collaboratively in a highly matrixed organization.
• Time-management skills and ability to multi-task.
• Excellent verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Health Quality (CPHQ).
• Medical record abstraction experience.
• Managed care experience.
• Ability to work across all levels of the organization, including working with executive audiences, vendors, providers, and the government as a customer.

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

Pay Range: $83,252 - $135,480 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.