This position will support the Dual SNP (DSNP) program. The position is responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. This role will be responsible for ongoing management of provider practice and community education on state specific quality measures. The Clinical Quality RN 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. This position will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. This position will also be responsible for direction and guidance on provider - focused, clinical quality improvement and management programs. This 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 or near Pittsburgh, PA, 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 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 specificationsThis is a work from home position; however you will travel locally to Physician offices up to 75% of the time. The ideal candidate will live in Allegheny or surrounding counties.
Required Qualifications:Current unrestricted RN licensure required in state of Pennsylvania 1+ year of experience as an RN 6+ months of quality Improvement experience, HEDIS, NCQA or clinical project work Proficiency in software applications that include Microsoft Word and Outlook Reliable transportation to travel to physician offices locally up to 75% of their time 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 Preferred Qualifications:Experience working in Medicaid and / or Medicare Health care and insurance industry experience, including regulatory and compliance Experience working with dual eligible LTC membersCareers 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, Health Care, Medicaid, Medicare, HEDIS, NCQA, ACO, PCMH, clinical data collection, provider relations, clinical practice transformation, implementation, quality improvement, compliance, health care analytics, chart review, managed care, LTC, long term care, DSNP, dual eligible special needs, Pittsburg, PA, Pennsylvania
Internal Number: 750681
About UnitedHealth Group
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.