Quality Improvement Specialist (HEDIS) II

Position Purpose: Takes a lead role in the development and maintenance of quality improvement related projects specific to HEDIS Hybrid Operations. The position serves as the primary owner for assigned HEDIS measures and leads complex quality improvement initiatives to support the health plans.

Key Details: Applicants for this job have the flexibility to work remote from home anywhere in the United States.

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.

• Train providers, health plans and staff in methodologies and tools of continuous quality improvement and HEDIS abstraction and over-read processes.
• Provide clinical support to the medical record abstraction, over-read and audit processes.
• Monitor performance on established contractual quality indicators.
• Analyze, track and trend results.
• Prepare for and participate in meetings with various committees, state agencies, providers, health plans, vendors, and stakeholders.
• Recommend, develop, and implement quality performance improvement plans (PIPs) with management utilizing the PDSA model.
• Monitor and report PIPs progress through closure.
• Serves as primary owner for assigned HEDIS measures, including year-round pseudo-claims performance, gap identification, and intervention and strategy planning.
• Supports department leadership in project and strategy development; Leads quality improvement initiatives involving complex or high-risk HEDIS measures with market-wide impact.
• Provide functional and technical knowledge regarding overall program requirements and operations.
• Provides guidance on complex abstraction scenarios, team training, and measure interpretation using critical clinical abstraction knowledge.
• Demonstrates advanced proficiency across all phases of clinical medical record abstraction, including data entry, over read, and inter-rater reliability (IRR/third level over read), while serving as a mentor and resource to team members by providing guidance on measure interpretation, abstraction standards, and quality improvement best practices.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Bachelor’s degree in Nursing, Healthcare, or Quality (including HEDIS measures or NCQA) or equivalent experience in related healthcare experience.

Requires 2+ years of experience in Quality. Knowledge of HEDIS & performance measures strongly preferred.
 

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.
 

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, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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