Quality Improvement Specialist

4 weeks ago


Las Vegas, Nevada, United States Centene Corporation Full time

Transform the health of our communities, one person at a time, as a Quality Improvement Specialist at Centene Corporation. This role is responsible for establishing and fostering healthy working relationships between large physician practices, IPAs, and Centene. You will educate providers and support provider practice sites regarding National Committee for Quality Assurance (NCQA) HEDIS measures and risk adjustment. Your expertise will be invaluable in providing education for HEDIS measures, appropriate medical record documentation, and appropriate coding. You will assist in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS and documentation standards. As a resource for health plan peers, you will provide guidance on HEDIS measures, appropriate medical record documentation, and appropriate coding. You will support the development and implementation of quality improvement interventions and audits in relation to plan providers.

  • Deliver, advise, and educate provider practices and IPAs in appropriate HEDIS measures, medical record documentation guidelines, and HEDIS ICD-9/10 CPT coding in accordance with state, federal, and NCQA requirements.
  • Collect, summarize, trend, and deliver provider quality and risk adjustment performance data to identify and strategize/coach on opportunities for provider improvement and gap closure.
  • Collaborate with Provider Relations and other provider-facing teams to improve provider performance in areas of Quality, Risk Adjustment, and Operations (claims and encounters).
  • Identify specific practice needs where Centene can provide support.
  • Develop, enhance, and maintain provider clinical relationships across product lines.
  • Maintain Quality KPI and maintain good standing with HEDIS Abstraction accuracy rates as per corporate standards.
  • Ability to travel up to 75% of time to provider offices.
  • Perform other duties as assigned.
  • Comply with all policies and standards.

Education/Experience: Bachelor's degree or equivalent required. 3+ years of experience in HEDIS record collection and risk adjustment (coding).

License/Certification: One of the following required: CCS, LPN, LCSW, LMHC, LMSW, LMFT, LVN, RN, APRN, HCQM, CHP, CPHQ, CPC, CBCS.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and 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. Total compensation may also include additional forms of incentives.



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