Job Description
Job Description
Job Summary
Molina’s Quality Management function implements, oversees, and maintains new and existing healthcare quality monitoring activities and programs; ensures quality monitoring audits and investigations are performed in accordance with prescribed quality standards; informs data collection, reporting, and analysis to monitor key quality management activity; and provides direction and implementation of federal/state quality management compliance activities.
Job Duties
The Sr Specialist, Quality Management (RN) contributes to the quality management functions.
• 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 of monitoring of placement settings.
• Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately in order to present results to key departmental management and other Molina 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 the 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.
• Is 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.
• Evaluates project/program activities and results to identify opportunities for improvement.
• Surfaces to Manager and Director any gaps in processes that may require remediation. In particular, the Senior Specialist may be asked to focus on parts of the process where a clinician's perspective would be valuable to uncover process gaps or limitations.
• Monitors and ensures that key quality activities are completed on time and accurately in order to present results to key departmental management and other Molina departments as needed.
Job Qualifications
Required Education
• Bachelor's Degree or equivalent combination of education and work experience.
Required Experience/Knowledge, Skills & Abilities
• Min. 3 years experience in healthcare with minimum 1 year experience in quality management and clinical quality investigations, or equivalent experience.
• Critical thinking skills.
• Strong communication skills, both verbally and written.
• Ability to interact effectively with health plan clinical leaders and peers across the organization.
• Proficient in Microsoft Office tools (Outlook, Excel, etc.)
Required License, Certification, Association
QM Nurse:
• Arizona-licensed RN or a Licensed Practical Nurse (LPN) with current Licensure under the Arizona State Board of Nursing (BON)
QM BH Nurse:
• Arizona-licensed registered nurse practitioner licensed as an adult, psychiatric and mental health nurse, or
• Arizona-licensed registered nurse with: a. A psychiatric-mental health nursing certification, or b. One year of experience providing behavioral health services.
Preferred Education
• Master’s degree in related discipline or equivalent work experience.
Preferred Experience
• 2 years medical record abstraction experience.
• 1 year 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.
Preferred License, Certification, Association
• Certified Professional in Health Quality (CPHQ)
PHYSICAL DEMANDS:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Info
Job Identification: 2029328
Job Category: Quality and Risk Adjustment
Posting Date: 2024-12-05T18:50:56 00:00
Job Schedule: Full time
