UnitedHealth Group Sr. Clinical Quality RN - Telecommute in Milwaukee, WI in Milwaukee, Wisconsin
There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)
The Registered Nurse CPC will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. Position is responsible for the direction and guidance on provider-focused clinical quality improvement and management programs. The 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.
If you are located in Milwaukee, WI, you will have the flexibility to telecommute* as you take on some tough challenges. This position will have up to 75% local travel in the Milwaukee, WI area. Additional cities in this territory include: Madison, Kenosha, Racine, and other cities as needed.
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
Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS/State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
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 Health Plan Quality Director
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.
Based on medical record audit findings, provides follow-up education, practitioner intervention, and measurement as needed to drive quality improvement
Current unrestricted RN licensure required in the state of operation
5+ years clinical experience, or other relevant experience
2+ years of quality improvement experience, or other relevant experience
Ability to travel to physician offices locally up to 75% of their time
Intermediate Microsoft skill including Word, Excel, and PowerPoint
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
Ability to make formal presentations within the context of their role
Ability to use databases and prepare reports as needed
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, Quality Nurse, Quality Improvement, Quality, HEDIS, CMS, NCQA, clinical, healthcare, managed care, Medicare, Medicaid, Milwaukee, WI, Wisconsin, Telecommute, Telecommuter, Telecommuting
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