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) Will travel in King County in Seattle Washington and Pierce County in Tacoma up to 75% of the time. 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 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 visitsMaterials 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)Works closely with the Health Plan Chief Medical Director(s) and other appropriate stakeholders implementing and monitoring the quality performance of value based provider contracts and reporting of findings at joint operations meetings 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 Will travel in King County in Seattle Washington and Pierce County in Tacoma up to 75% of the time.h 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 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 specifications If required, supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection or for other focus studies as directed by the Plan Quality Director Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases and researching to identify members' encounter history Participates in or coordinates with other department projects as needed Needs to works independently and within an integrated team in a highly matrixed environment May do additional duties as assigned
Required Qualifications:Bachelor Degree in Nursing, Behavioral Health, Psychology, Social Work or related field Experience working in Managed Care Industry Experience working in Medicaid and / or Medicare 2+ years of quality improvement experience or other relevant experience Ability to make formal presentations within the context of their role Ability to use databases and prepare reports as needed Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint Problem solving skills Excellent verbal and written communication skills Role requires travel to physician offices locally up to 75% of the timePreferred Qualifications:Insurance industry experience, which should include performance improvement / quality management Knowledge of HEDIS, NCQA, governing and regulatory agency requirements and provider value based contracting If RN: an unrestricted RN license in the state of Washington Multilingual candidatesCareers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 14 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm) 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, Clinical experience, Medicaid, Medicare, Insurance Industry, Clinical Practice Consultant, HEDIS, NCQA, CMS, Quality Improvement, Tacoma, Seattle, WA, Washington,
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.