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This position is responsible for ongoing HEDIS collection and improvement activities at the health plan and reports to the Quality Management Leader.
To be considered for this role, you must live in or near any of the following counties in TX: Jefferson or Harris Counties and surrounding SDAs
You will have the flexibility to telecommute* as you take on some tough challenges. This position will require travel up to 75% of the time to providers offices.
- Coordinates and performs onsite medical record reviews at provider offices to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards and where assigned investigation of quality of care and member complaints relative to quality of care and service
- Support continuum of member care by identifying members in need of health education, case management, etc.
- Educates providers and office staff on proper coding and billing practices, HEDIS and state-mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria
- Solicit identification of barriers the office faces in providing care to members
- Supports the HEDIS medical record chase to support optimum HEDIS and quality metric reporting
- Supports quality improvement program studies requesting records from providers, maintaining databases and researching to identify members' provider encounter history
- Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education and disparity programs, as assigned
- Performs annual medical record evaluation, follow-up education, practitioner intervention, measurement (QI 13) as required
- Enter documentation of findings in identified database
- Generally works independently, under the supervision of the Quality Management leader
- Participates in or coordinates with other department projects as needed
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
- Current unrestricted RN licensure in Texas
- 5+ years of clinical experience in any setting (with 2+ years in acute care)
- 2+ years of quality improvement experience (chart review, compliance, HEDIS, investigation, etc.)
- Experience reviewing and evaluating medical records with attention to detail
- Experience working in Medicaid and / or Medicare health care and insurance industry, including regulatory and compliance requirements
- 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
- Access to reliable transportation that will enable you to travel to client and / or patient sites within a designated area
- Ability to make formal presentations in front of committee and work group environments
- Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft Outlook, and Internet browsers
- Bachelor’s degree
- Experience in complex populations
- Bilingual - English / Spanish
- Ability to interact with medical staff, peers and internal company staff at all levels
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, Registered Nurse, HEDIS, Quality, Compliance, Medicaid, Provider, Clinical Data Collection, Spanish, Telecommute, Telecommuter, Telecommuting, Remote, Northeast Texas, Northcentral, Houston, Telecommute, Telecommuter, Telecommuting, CPC, Clinical Practice Consultants, NCQA, Quality, Quality Measures, Hidalgo, Jefferson, North Central, Nueces Counties, Texas, Harris, TX