Abstractions and Overread experience highly preferred.

MedSurge experience highly preferred.

Position Purpose:
Conduct review of delegated entities for compliance with quality, service performance and utilization, credentialing reviews and medical record audits. Perform community activities related to clinical initiatives such as health fairs and communicate with agencies and providers.

• Perform quality on site reviews of delegated entities, physician office/clinics, resolve quality issues, generate written summary of findings and follow up as directed by the Medical Director and/or Credentialing and Quality Improvement Committee (QIC).

• Document, investigate and resolve formal and informal complaints, risk management and sentinel events related to quality of care issues.

• Audit medical records, review administrative claims and analyze data and interventions for quality improvement studies and activities

• Function as the primary liaison between community resources/agencies and the company related to clinical initiatives and technical guidance.

• Schedule and chair meetings with delegated entities in accordance with their contract.

• Gather data and compile various utilization and quality improvement reports.

• Develop and implement Corrective Action Plans.

• Recommend changes/enhancements to the Quality Improvement policies and procedures.

• Identify best practices, research new processes and recommend program enhancements.

• Coordinate QIC activities and monthly meetings.

• Oversee the enforcement of contract terms regarding data submission for delegated entities.

• Participate in the development of reporting and data outcome reports.
• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience:
Bachelor’s degree in Nursing preferred. 3+ years of clinical, quality improvement or healthcare experience. 2+ years of experience in quality function in a healthcare setting.

License/Certification: LPN, LVN, RN, PA, or LCSW license preferred. CPHQ (Certified Professional in Healthcare Quality) 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