Clinical Quality Improvement Specialist
7 days ago
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities, and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable, and equitable.
The Senior Clinical Quality RN will focus on tasks that occur in accordance with State, CMS, or other requirements as applicable. This position will also be responsible for direction and guidance on provider-focused, clinical quality improvement and management programs.
This role assists contracted providers with analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS, NCQA, and other tools. Position reports to the Quality Leadership of the Health Plan.
This is a home-based office position with field responsibilities up to 75% of the time. Travel to counties of Cherokee, Crawford, Bourbon, Linn, Miami, Johnson, Wyandotte, Douglas, Franklin, Anderson, Allen, Neosho, Labette, Montgomery, Wilson, Woodson, Coffey, Osage, Greenwood, Elk, and Chautauqua, KS based on business needs.
If you are located within Kansas City, KS or surrounding counties, you will have the flexibility to telecommute as you take on some tough challenges.
Primary Responsibilities:- Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement.
- Serves as subject matter expert (SME) for assigned HEDIS/State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State Measure rates.
- Participates, coordinates, and/or represents the Health Plan at community-based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned.
- Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards.
- Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion.
- Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state-specific measures and technical specifications.
- Competitive base pay.
- A full and comprehensive benefit program.
- Performance rewards.
- A management team who demonstrates their commitment to your success.
- 8 Paid Holidays.
- Medical Plan options along with participation in a Health Spending Account or a Health Saving account.
- Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage.
- 401(k) Savings Plan, Employee Stock Purchase Plan.
- Education Reimbursement.
- Employee Discounts.
- Employee Assistance Program.
- Employee Referral Bonus Program.
- Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.).
- Current unrestricted RN licensure in state of Kansas.
- 2+ years clinical experience as an RN.
- 2+ years of experience with quality improvement.
- Intermediate level of proficiency in MS Office including Word, Excel, Outlook.
- Current, non-restricted state of Kansas driver's license and state-required insurance.
- Access to reliable transportation and the ability to travel up to 75% of the time to providers.
- Access to a designated quiet workspace in your home (separated from non-workspace areas) with the ability to secure Protected Health Information (PHI).
- Live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.
- Bachelor's Degree in Nursing or related field.
- HEDIS, NCQA experience.
- Experience leading teams or individuals for better quality outcomes.
- Health care and insurance industry experience, including regulatory and compliance.
- Background in Managed Care.
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