The Bilingual Sr. Clinical Quality RN will drive consistency, efficient processes and share best practices, in a collaborative effort with the provider and large or complex groups, designed to facilitate a minimum 4 STAR quality performance. The Sr CQC will participate in quality improvement initiatives, attend monthly or joint operating committee meetings, develop recommendations for quality remediation plans and create tools and databases to capture relevant data for each region. This position will work collaboratively with each regional/market team and their leadership in a matrix relationship. This position may serve as the team lead for the clinical quality consultants in the assigned market and has responsibility for the network’s quality performance.
1. Develop market business plans to motivate providers and large or complex group leadership to engage in improving Stars measures to be 4 STARS or higher
2. Place outbound calls to members to ascertain information from the patient regarding HEDIS and Quality measures related to their care as well as obtain member information regarding any possible gaps in care.
3. Provide analytical interpretation of Stars and HEDIS reporting, including executive summaries to plan and provider groups
4. Be the primary subject matter expert for all STARS related activities within their assigned market(s) working within a matrix relationship which includes Quality corporate operations and Regional/Market operations.
5. Lead or participate and present in weekly, Monthly, Bi-monthly, Quarterly and/or Annual business Review meetings related to STAR activities which summarize provider and large group performance and market performance as requested by or required by Quality or Regional leadership.
6. Analyze and evaluate provider and large group structure and characteristics, provider group/provider office operations and personnel to identify the most effective approaches and strategies
7. Assist in developing of training and analytical materials for Stars and HEDIS The information listed above is not comprehensive of all duties/responsibilities performed. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice.
8. Identify and assess decision makers and other key provider group personnel with a focus on identifying barriers to achieving targeted outcomes, focus communications and efforts accordingly 9. Develop solution-based, user friendly initiatives to support practice success 10. Performs all other related duties as assigned
▪ Registered Nurse (within the states in which service is being delivered)
▪ Bilingual in Spanish
4 or more years of healthcare experience, including experience in a managed care setting
▪ 2 or more years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role.
▪ 2 or more years of experience in provider facing interactions, including provider education.
▪ 2 or more years of experience with data analysis and/or quality chart reviews. Must be able to review data and provide recommendations for improvement
▪ Strong knowledge of the Medicare market, products and competitors
▪ Proven ability to influence providers to change behavior and drive improvement in quality performance
▪ Experience in managed care working with network and provider relations
▪ Strong communication and presentation skills
▪ Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels.
▪ Ability to solve process problems crossing multiple functional areas and business units
▪ Strong problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
▪ Experienced using Microsoft office applications, including databases, word-processing, and excel spreadsheets. Must be proficient in Excel
▪ Excellent customer service skills Preferred Education, Experience & Skills
▪ Billing and CPT coding experience
▪ Call Center Experience ▪ Clinical data abstraction experience
▪ Adaptable to change ▪ Good business acumen, especially as it relates to Medicare
▪ Undergraduate degree preferred, post graduate degree highly preferred
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.
Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $66,100 to $118,300. The salary range for Connecticut / Nevada residents is $72,800 to $129,900. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.