Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)
The 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.
If you are located in San Antonio, TX, you will have the flexibility to work remotely* as you take on some tough challenges.
- 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
- 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
- Provide analytical interpretation of Stars and HEDIS reporting, including executive summaries to plan and provider groups
- 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
- 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
- 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
- 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
- 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
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.
Monday - Friday 9am to 6pm
Will rotate a Saturday every couple of months and when you work a Saturday you have the Monday of that week off.
- Current unrestricted Texas RN License or Compact State License
- 4+ years of healthcare experience, including experience in a managed care setting
- 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role
- 2+ years of experience in provider facing interactions, including provider education
- 2+ years of experience with data analysis and/or quality chart reviews. Must be able to review data and provide recommendations for improvement
- Experience in managed care working with network and provider relations
- Experienced using Microsoft office applications, including databases, word-processing, and excel spreadsheets. Must be proficient in Excel
- Exceptional knowledge of the Medicare market, products and competitors
- Undergraduate degree, post graduate degree
- Billing and CPT coding experience
- Call Center Experience
- Clinical data abstraction experience
- Bilingual in Spanish
- Good business acumen, especially as it relates to Medicare
- Adaptable to change
- Proven ability to influence providers to change behavior and drive improvement in quality performance
- Solid 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
- Solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
- Excellent customer service skills
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.
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
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.