Clinical Quality Improvement Specialist

4 weeks ago

Lee's Summit, Missouri, United States UnitedHealthcare Full time
Senior Clinical Quality RN

At UnitedHealthcare, we're simplifying the healthcare experience, creating healthier communities, and removing barriers to quality care. Our mission is to help people live healthier lives and make the healthcare system work better for everyone.

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.
What are the reasons to consider working for UnitedHealth Group?
  • Paid Time Off which you start to accrue with your first pay period plus 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.).
  • More information can be downloaded at: http://uhg.hr/uhgbenefits.
Required Qualifications:
  • 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.
Preferred Qualifications:
  • BSN, Master's Degree (or higher) in 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.

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

At UnitedHealth Group, our mission is to help people live healthier lives and make the healthcare 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.

#RPO #Red

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