Senior Clinical Quality Nurse Specialist

2 days ago

Kansas City, Kansas, United States UnitedHealthcare Full time

At UnitedHealthcare, we're dedicated to simplifying the healthcare experience, fostering healthier communities, and removing barriers to quality care. Our work impacts the lives of millions of people for the better. Come build a more responsive, affordable, and equitable healthcare system. Ready to make a meaningful difference? Consider joining our team as a Senior Clinical Quality Nurse Specialist.

This role focuses on tasks aligned with State, CMS, or other applicable requirements. You'll provide direction and guidance on provider-focused, clinical quality improvement and management programs. You will assist contracted providers in 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.

This position reports to the Quality Leadership of the Health Plan. As a Senior Clinical Quality Nurse Specialist, you'll be responsible for assisting 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. You will also serve as a subject matter expert (SME) for assigned HEDIS / State Measures, preventive health topics, lead efforts with clinical teams to research and design educational materials for use in practitioner offices; serve as liaison with key vendors supporting HEDIS / State Measures; consult with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates.

Your primary responsibilities will include:

  • Supporting effective deployment of programs 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
  • Serving as an SME for assigned HEDIS / State Measures, preventive health topics, leading efforts with clinical teams to research and design educational materials for use in practitioner offices; serving as liaison with key vendors supporting HEDIS / State Measures; consulting with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates
  • Participating, coordinating, and/or representing 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
  • Coordinating and performing 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
  • Investigating gaps in clinical documentation where system variation has impact on rate calculation, providing feedback to appropriate team members where issues are verified, and monitoring resolution to conclusion
  • Working with providers on standards of care, and advising providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state-specific measures and technical specifications

We offer a competitive salary range of $85,000 - $115,000 per year, plus benefits that include paid time off, medical plan options, dental and vision insurance, life and AD&D insurance, 401(k) savings plan, employee stock purchase plan, education reimbursement, employee discounts, employee assistance program, employee referral bonus program, and voluntary benefits such as pet insurance, legal insurance, and long-term disability coverage. We're committed to helping you grow your career and provide development opportunities for other roles you may be interested in.

Required qualifications for this role include:

  • Current unrestricted RN licensure in the state of Kansas
  • 2+ years of clinical experience as an RN
  • 2+ years of experience with quality improvement
  • Intermediate level of proficiency in MS Office including Word, Excel, Outlook
  • 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

We welcome candidates who possess a BSN, Master's Degree (or higher) in a clinical field, HEDIS, NCQA experience, experience leading teams or individuals for better quality outcomes, healthcare and insurance industry experience, including regulatory and compliance, background in managed care, and a current, non-restricted state of Kansas driver's license and state-required insurance.

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