You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.Position Purpose: Perform quality improvement activities including, but not limited to, member and or provider outreach and or education, care gap closure documentation, medical record data abstraction and over-reads of HEDIS and other quality related measures.
Conducts member and/or provider outreach to close quality care gaps for CMS Medicare Advantage Stars, Medicaid, and Marketplace Quality measures.
Coordinates and facilitates member access to various healthcare providers for services, as necessary.
Enters pertinent clinical information into various medical management systems.
Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
Educates providers on HEDIS measures and documentation requirements based on provider medical records
Collects and summarizes performance data and identifies opportunities for improvement to educate providers and improve overall quality metric performance.
Monitors HEDIS quality improvement initiatives that may include development and implementation of preventive health and chronic disease outcome improvement interventions such as: newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys. May perform data abstraction and or over-reads for HEDIS Hybrid quality measures.
Performs other duties as assigned
Complies with all policies and standards
Education/Experience: Graduate from an Accredited School of Nursing (Registered Nurse), requiredBachelor's Degree Bachelor’s degree in social work, counseling, healthcare or related field. required3+ years Health Plan Quality Improvement required: 3+ years Relevant experience with HEDIS quality measure criteria, medical record abstraction and over-read activities required3+ years For Behavioral Health assignments, experience in Behavioral health, alcohol and or substance use disorders. preferredRN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse, State of Illinois Upon Hire required orLCSW- License Clinical Social Worker Upon Hire requiredValid IL driver's license Upon Hire required and: ability to travel 25% Upon Hire requiredPay Range: $54,000.00 - $97,100.00 per yearCentene 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.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
