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 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. The Registered Nurse CPC will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. Position responsible for direction and guidance on provider - focused, clinical quality improvement and management programs. The 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. Candidate must live in Springfield, Ohio as this is a telecommuter position working with providers in these areas. 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 visits Materials 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) 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 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 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 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 matrix environment
Required Qualifications:Current unrestricted RN licensure required in the state of Ohio Undergraduate degree or equivalent experience 6+ years clinical experience 3+ years of quality improvement experience, or other relevant experience Experience working in Medicaid and/or Medicare Knowledge & demonstrated experience with continuous QI concepts and tools i.e. audits, chart review, knowledge of current CPT and ICD10 coding 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 Experience preparing and presenting information to clinical and executive level leadership Intermediate computer literate and have MS Word, Excel, Outlook, and Internet demonstrated skills Ability to foster teamwork with all levels of management and staff within highly matrix organization Ability to work independently with minimal supervision and within a team Proper etiquette including customer service relation techniques, superior verbal and communications skills Strong decision making, accuracy and attention to detail Experience in meeting strict deadlines and adhering to strict standards Role requires travel to physician offices locally up to 75% of their time Proficient with Excel, Intermediate computer literate and have MS Word, Outlook, and Internet demonstrated skillsPreferred Qualifications:Health care and insurance industry experience, including regulatory and compliance Master's Degree Clinical process improvement experience Clinical quality improvement experience Population Health (PCMH) experienceCareers 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, physicians, providers, practices, CPC, Clinical Practice Consultant, Medicare, Medicare, quality improvement, audits, HEDIS, NCQA, Springfield, Ohio, OH
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.