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) Position responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. Position responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse CPC will work closely to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. Primary Responsibilities:Serves as subject matter expert (SME) for assigned Medicaid HEDIS / CMS 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 Medicaid HEDIS / CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve Medicare HEDIS / CMS Measure rates Identify patient care opportunities and collaborate with physician practices to ensure appropriate member appointments and care 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 Educates providers and office staff on proper clinical documentation, coding and billing practices, CMS mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria, to drive quality improvement 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 CMS specific measures and technical specifications
Required Qualifications:RN, LPN, or Foreign Medical Graduate 3+ years clinical experience in a physician practice, outpatient facility or a FQHC 2 years of Medicaid experience Intermediate level in software applications that include, but are not limited to, Microsoft Word and Microsoft Excel Travel to physician offices locally up to 75% of their timePreferred Qualifications: 2 years of HEDIS experience 2+ years of quality improvement experience Bilingual Health care and insurance industry experience, including regulatory and compliance Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, governing and regulatory agency requirements and the managed care industryCareers 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) 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, Nurse, Registered Nurse, LPN license, Foreign Medical Graduate, physicians, providers, practices, CPC, Clinical Practice Consultant, Medicare, quality, HEDIS, Genesee, Wayne, Ontario, Monroe County, Geneva, Corning, Rochester, New York, NY
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.