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Sr. Clinical Practice Consultant - Telecommute in Syracuse, Buffalo, Rochester, NY job in Atlanta at UnitedHealth Group

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Sr. Clinical Practice Consultant - Telecommute in Syracuse, Buffalo, Rochester, NY at UnitedHealth Group

Sr. Clinical Practice Consultant - Telecommute in Syracuse, Buffalo, Rochester, NY

UnitedHealth Group Work From Home, GA Full Time

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

Position responsible for strategically developing clinically oriented provider and community-based partnerships in order to increase quality scores based on state specific quality measures. Position responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse CPC will work closely with the quality director to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. The Clinical Practice Consultant 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. Position reports to the Quality Leadership of the Health Plan. 

If you are located within Syracuse, Buffalo, Rochester, NY you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Front Facing Practice Level Leadership
  • Targeted Quality Improvement 
  • Gaps in Care Closure
  • Relationship Management, Internal and External
  • Community Engagement and Interaction 
  • Provider and Practice Education, Quality Oriented Health Topics
  • 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
  • Supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection, or for other focus studies as directed by the Plan Quality Director
  • Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases, and researching to identify members' encounter history
  • 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 to identify local level strategies to overcome barriers and close clinical gaps in care
  • 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
  • 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
  • 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
  • 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
  • Participates in or coordinates with other department projects as needed
  • Needs to work independently and within an integrated team in a highly matrixed environment
  • May do additional duties as assigned


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.

Required Qualifications:

  • Bachelor’s degree in Science or equivalent work experience 
  • 5+ years of clinical experience, or other relevant experience (clinical quality)     
  • 2+ years of quality improvement experience, or other relevant experience
  • 2+ years of quality improvement experience (chart review, compliance, HEDIS, investigation, etc.)
  • Experience working in Medicaid and/or Medicare
  • 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
  • Intermediate level Microsoft office 
  • Travel to physician offices locally up to 75% of their time
  • Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance

Preferred Qualifications:

  • Master’s degree
  • Current unrestricted RN licensure 
  • Health care and insurance industry experience, including regulatory and compliance
  • Medical Coding knowledge / training
  • Presentation skills (WebEx, Power Point)


To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies now require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles require full COVID-19 vaccination 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 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 bylower 48 law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.


Job Keywords: Sr. Clinical Practice Consultant, Clinical, Compliance, HEDIS, NCQA, Investigation, Medicaid, Medicare, Coding, Syracuse, Buffalo, Rochester, NY, New York

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