Senior Clinical Quality RN
1 week ago
The Clinical Performance Quality (CPQ) Clinical Programs Operations team supports Optum's Care Delivery Organizations by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close Medicare STARS/HEDIS gaps in care, including medication adherence, care for older adults, medication reconciliation post discharge, A1c, Blood pressure and statin therapy in patient with diabetes and cardiovascular disease. Our interdisciplinary service delivery team is comprised of Pharmacists, Registered Nurses, Pharmacy Technicians, and Care Coordinators.
The Registered Nurse will report into the Director of Clinical Programs. The Registered Nurse will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. In addition, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work to support the hours of operation of the business (Mon-Fri 9am-6pm Central).
You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Call center hours of operation are 9am-6pm CST.
Primary Responsibilities:
- Strictly adheres to department's metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests
- Primarily to make outbound calls and will help manage the inbound call queue from patients, patient representatives, providers and other medical staff, while strictly adhering to established protocols and scripting
- Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services
- Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments
- Educate patients on health conditions and necessity of routine screening and assisting with appointment scheduling (A1c, Controlling Blood Pressure, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.)
- Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided
- Review available medical records for core measures to submit for closure of HEDIS/STARS measures
- Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs
- Document thoroughly all calls and actions taken within core systems.
- Performs all other related duties as assigned
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- Active, unrestricted Registered Nurse license in state of residency
- Active Compact RN License (NLC) in state of residency
- Currently have or be able to obtain additional RN licensure in one or more of the following states: California, Connecticut, Nevada, New York, Oregon
- 5+ years of RN experience, including experience in a managed care setting
- 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role
- 2+ years of call center experience
- 2+ years of experience with data analysis and/or quality chart reviews. Must be able to review paper and electronic medical records and charts
- Proven solid knowledge of the Medicare HEDIS/Stars measures
- Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
- Ability to manage multiple complex, concurrent projects
- Proven excellent written and verbal communication and relationship building skills
- Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
- Experienced using Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets. Must be proficient in Excel
- Proven excellent customer service skills and communication skills
Preferred Qualifications:
- Undergraduate degree or post graduate degree
- Billing and CPT coding experience
- Clinical data abstraction experience
- Ability to be adaptable to change
- Proven good business acumen, especially as it relates to Medicare
- Bilingual with preference given to Spanish and Vietnamese
- RN licensure to cover all 50 states highly preferred
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Maryland, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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