Clinical Quality Specialist RN - Telecommute in Columbia

Employer
UnitedHealth Group
Location
Baltimore, MD
Posted
Sep 19, 2021
Closes
Sep 21, 2021
Ref
99859062
Function
Nurse
Industry
Insurance
Hours
Full Time
UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)If you are located in or near Columbia or Baltimore, MD, you will have the flexibility to telecommute* as you take on some tough challenges. Primary Responsibilities: 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 Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care Reports individual member quality of care concerns or trends of concern to the Quality Manager 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 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 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 Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy Documents and refers providers' non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database 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 specificationThis position requires training in the office for 3 weeks. There is an opportunity to work-at-home after the initial training. There are no weekend, nights, on-call or holiday work required. This role will cover the entire state.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: Undergraduate degree or equivalent experience5+ years clinical experience 2+ years of quality improvement experience Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint Travel to physician offices locally up to 75% of their timePreferred Qualifications: Experience working in Medicaid and/or Medicare Health care and insurance industry experience, including regulatory and compliance Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.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.Job Keywords: RN, registered nurse, HEDIS, NCQA, ACO, CMS, PCMH, Medicaid, clinical data collection, provider relations, clinical practice transformation, clinical transformation, implementation, quality improvement, compliance, health care analytics, chart review, managed care, Columbia, Baltimore, MD, Maryland, Telecommute, Telecommuting, Telecommuter

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