JOB DESCRIPTION Job Summary Provides senior level clinical support to quality team - contributing to quality management programs, initiatives, audits, data analysis and quality improvement surveys and state/federal quality compliance activities. Contributes to overarching strategy to provide safe, efficient and cost-effective member care. Essential Job Duties • 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 monitoring of placement settings. • Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately; presents results to key departmental leadership and other 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 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. • Demonstrates understanding of 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. • Raises any gaps in processes that may require remediation to appropriate leadership; may be asked to focus on parts of a process where a clinician's perspective would be valuable to uncover process gaps or limitations.
Molina Healthcare is a managed care organization that hires nurses for remote clinical review and care management roles supporting Medicare and long-term services members. Care Review Clinicians assess whether services are medically necessary and align with clinical guidelines and insurance policies, working with members and providers via phone and computer systems to verify benefits and eligibility. Care Managers conduct comprehensive member assessments, develop care plans, authorize waiver services, and coordinate care across the continuum for high-need members, including in-person home visits where required.
