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We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM


Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com


Job Category:

Medical and Clinical Operations



Approximate Salary:

Not Specified

Position Type:

Full Time

Manager, Quality Solutions Delivery Clinical Review - Telecommute

UHG - San Antonio, Texas

Posted: 12/13/2018

UnitedHealthcare’s Quality Solutions Delivery (QSD) is an integrated team serving all UnitedHealthcare businesses, focused on delivering operational efficiencies for centralized activities.  Clinical documentation accuracy is integral to the success of HEDIS® medical record review.


QSD combines talented individuals from many areas of quality. Our goal is extraordinary performance that exceeds the expectations of the constituents, customers and members we serve.


This position reports to the Associate Director, QSD Clinical Review. 


You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.


Primary Responsibilities:

  • Contribute to annual project plan to achieve all QSD Clinical Review tasks and objectives

  • Observe and comply with policies and procedures for assigned scope:

    • Abstraction (medical chart interpretation and data entry)

    • Inter-Rater Reliability (IRR)

    • Vendor Inter-Rater Reliability (VIRR)

    • Medical Record Review Validation (MRRV)

  • Conduct interviews and hire appropriate resources to satisfy all operational objectives including seasonal staffing

  • Manage assigned team and measures and operational scope:

    • Abstraction (medical chart interpretation and data entry) / Medical Record Review Validation (MRRV)

    • Vendor Inter-Rater Reliability (VIRR) / Inter-Rater Reliability (IRR)

      • serve as liaison to vendors for VIRR results

  • Ensure engagement and participation in training programs for all clinical review staff in structure

  • Maintain expertise on all measures within NCQA/Stars measures and HEDIS®-like performance guarantee or custom state measure requirements in QSD scope

  • Lead domestic resources and facilitate engagements and provide support for international resources for clinical operations

  • Be fully versed and trained and ensure team trained on all HEDIS® Software, Onbase® & rateLIFT

  • Conduct abstraction activities for charts collected internally and in scope for QSD Clinical Review

  • Participate and ensure staff engagement in all User Acceptance Testing (UAT) pertaining to HEDIS® Software, Onbase® and rateLIFT

  • Engage with international resource programs, Optum Global Solutions, to resource team where appropriate

  • Monitor and manage staff engaged in all activities above

  • Design and facilitate implementation development programs for all permanent direct and indirect reports

  • Uphold UnitedHealthcare Cultural Values

For QSD Clinical Review Group assignment:

  • Conduct Inter-Rater Reliability assessments on all internal abstraction staff as well as vendor partner clinical abstractions

    • Identify and document trends with any abstraction concerns

    • Engage directly with staff to resolve individual errors within UHC or engage with vendor liaisons to resolve errors identified with vendor partners

  • Conduct Medical Record Review Validation

    • Identify and document trends

    • Engage with vendor liaisons to resolve errors identified with vendor partners

    • Engage with Roadmap/Auditor team on any issues that require clarification

    • Ensure errors identified are taken to resolution

  • Ensure all charts are pulled and documented to support final MRRV audits

    • Develop and support any corrective action plans, if required

  • Conduct analysis of retrospective operations and engage teams to identify improvements

  • Implement process improvements annually

  • Conduct year round abstraction and IRR activities for all charts collected internally (within volume scope)

 Required Qualifications:

  • Minimum 4 year degree or equivalent experience  
  • Clinical and/or Health Education experience
  • 3+ years Healthcare/Health Plan experience
  • Experience with NCQA and STARS measures
  • Experience with auditing medical records
  • 1+ years managerial/supervisory experience
  • 2+ years of proven success managing, implementing or auditing quality programs
  • Demonstrated ability to assist with focusing activities toward a strategic direction and achieve targets
  • Strong proficiency with Microsoft Office applications, including: Word, Excel and PowerPoint

Preferred Qualifications:

  • RN or LPN
  • Experience working with international resources for clinical process operations
  • Basic statistical knowledge and application of continuous quality improvement concepts, such as Six Sigma or PDCA 

Soft Skills:         

  • Strong project management skills
  • Excellent team development skills
  • Strong interpersonal skills
  • Strong time management and prioritization skills
  • Strong written and verbal communications skills

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can 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, LPN, Health Education, Clinical Review, Manager, Supervisor, Leadership, Quality Improvement, Process Improvement, Performance Improvement, Auditing, Health Care Analytics, Managed Care, Healthcare, HEDIS®, STARs, NCQA, Project Management, Six Sigma, PDCA,  Chicago, Atlanta, San Antonio, Phoenix, IL, Illinois, GA, Georgia, TX, Texas, AZ, Arizona, Telecommute, Work from Home, UHG, UHC, UnitedHealthcare

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