Clinical Quality RN - Telecommuter - Southwestern & Southeastern, KS
About the Job
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 Clinical Quality RN 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 Covering the Southwestern, Topeka, Dodge City, Great Bend, Liberal and Southeastern Kansas area, you will have the flexibility to telecommute* as you take on some tough challenges.
- 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
- 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
- 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
- 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
- Current unrestricted RN licensure required in state of Kansas
- 2+ years clinical experience as an RN
- Intermediate to Advanced Computer / typing proficiency to enter / retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications, Microsoft office (including excel)
- Knowledge of one or more of: Preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements and the managed care industry, quality improvement, implementation clinical standards of care
- Travel up to 75% in the assigned territory
- Health care and insurance industry experience, including regulatory and compliance
- 2+ years quality improvement experience
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: Clinical Analyst, Clinical Quality Analyst, Quality Analyst, RN, Registered Nurse, Nurse, data, Preventive health standards, HEDIS, NCQA, governing and regulatory agency, managed care, quality improvement, implementation clinical standards of care, quality, health plan, clinical guidelines, Kansas, Overland Park, KS