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- Sacramento, CA
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Clinical Quality Analyst - Telecommute - Sacramento, CA
UnitedHealth Group • Sacramento, CA
Posted 9 days ago
If you are located in Sacramento, CA 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
- 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
- Conducts member outreach to provide education on care gaps and utilizes motivational interviewing techniques to encourage members to access care for needed services, coordinating scheduled visits with provider offices
- 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
- 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
- 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 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
- Prepares educational materials for training providers and support staff in HEDIS measures, clinical transformation practices, care gap roster management, and population management techniques
- Supports the plan in preparing member education materials, educational newsletters, and attending community events as needed
- Participate in regulatory Quality Improvement Projects, implementing interventions and other monitoring activities
- Supports the plan in monitoring effectiveness of member engagement programs and provider incentive programs. Escalates feedback or trends of concern to the Health Plan Quality Director
- 1+ year(s) of experience in Managed Care or Primary Practice setting, including regular interaction with Providers regarding Clinical Quality Improvement
- Proficiency using a PC in a Windows environment, including Microsoft Word
- Ability to Travel to physician offices locally up to 75% of the time in Sacramento County
- Access to reliable transportation
- Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements
- 1+ year(s) experience in clinical setting or Federally Qualified Health Center
- Experience working in Medicaid and/or Medicare
- Bachelor’s or Master’s degree in Public Health or related field
- Current unrestricted RN licensure in the State of California
- Account Management 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.