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 Nurse 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.
If you are located in or near Grand Rapids, MI, you will have the flexibility to telecommute* as you take on some tough challenges. This is a field-based role with a home-based (telecommute, work at home) office. You will be spending approximately 75% of the time in the field within an assigned coverage area. Candidates must be willing to travel within the 60 miles of the Grand Rapids, MI area.
- Works with an interdisciplinary team to document and report quality measures to meet state regulatory requirements specific to the dual eligible Special Needs Population (SNP)
- 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
- 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
- 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, to drive quality improvement
- 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
- Current, unrestricted RN license in the state of Michigan
- 3+ years clinical experience
- 2+ years of experience of quality improvement
- Experience working in Medicare and/or Medicaid
- Intermediate- Advanced software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint
- Ability to travel to physician offices locally up to 75% of the time
- Managed Care industry experience
- Knowledge of HEDIS, NCQA, governing and regulatory agency requirements and provider value based contracting
- Bilingual candidates
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: RN, Nurse, Registered Nurse, Clinical Nurse, Clinical Analyst, Senior Clinical Quality Analyst, Clinical Analyst, Analyzing, Analyze, audit, Exvel, reporting, sorting, filtering, formula, Excel, Access, data, data analyst, manipulation software, quality, NCQA,HEDIS.CAHPS, SQL, quality improvement projects, PM, Project, Grand Rapids, MI, Michigan