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 Senior Clinical Quality RN will be responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. Position is responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse will work closely with the quality director 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. If you are located in the Green Bay, Wisconsin area, 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 indentifying 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 on key health related issues. 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 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 historyThis is a field based position that requires travel throughout Green Bay, Wisconsin and surrounding area.
Required Qualifications:Current, unrestricted RN licensure for the state of Wisconsin 5+ years clinical experience 1+ years of HEDIS or quality improvement experience Experience working in Medicaid and / or Medicare Ability to travel locally up to 50% to physician officesPreferred Qualifications:Bachelor's degree Managed Care experience Health care and insurance industry experience, including regulatory and compliance Knowledge of one or more of: clinical standards of care, preventive health standards, NCQA, 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) *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: Registered Nurse, Nurse, RN, Quality, Quality Improvement, Analyst, Health Care, Medicaid, Medicare, HEDIS, STARS, NCQA, Managed Care, Clinical Practice Consultant , Regulatory Compliance, CMS, Clinical, Project Manager, Work at Home, Green bay, WI, Wisconsin, Telecommute, Telecommuter, Telecommuting, Remote, UHC, UnitedHealthcare, Community and State, Public Sector, UHG
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.