Clinical Practice Consultant RN

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There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)

The Clinical Practice Consultants are experienced RN's who are assigned practices with large panels that have members who are non compliant in HEDIS measures.  They also coordinate activities with Provider Advocates and others to provide a comprehensive full spectrum of education and support to the practices.  The Clinical Practice Consultants are responsible for ongoing HEDIS collection and improvement activities at the health plan and report to the Quality Management Leader.

Primary Responsibilities:

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  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


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  Support continuum of member care by identifying members in need of health education, case management, etc.


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  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


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  Solicit identification of barriers the office faces in providing care to members 


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  Supports the HEDIS medical record chase to support optimum HEDIS and quality metric reporting


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  Supports quality improvement program studies requesting records from providers, maintaining databases, and researching to identify members' provider encounter history


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  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


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  Performs annual medical record evaluation, follow-up education, practitioner intervention as required


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  Enter documentation of findings in identified database


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  Generally works independently, under the supervision of the Quality Management leader


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  Participates in or coordinates with other department projects as needed

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  RN with active, unrestricted licensure in state of Maine 


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   3 or more years clinical experience


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  Previous HEDIS abstraction experience is strongly preferred.


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  Experience working in Medicaid and/or Medicare health care and insurance industry, including regulatory and compliance requirements 


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   Level of proficiency with Microsoft Office applications including Word, Excel, Access and PowerPoint


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  Ability to travel to Providers' offices in service area


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   Strong organizational skills and ability to work both independently and with teams


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  Ability to evaluate medical records with attention to detail 


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   Ability to interact with medical staff, peers, and internal company staff at all levels 


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   Ability to make formal presentations in front of committee and work group environments


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  Must have reliable transportation.
  

   

Careers at UnitedHealthcare Medicare & Retirement.   The Boomer generation is the fastest growing market segment in health care. And we are the largest business in the nation dedicated to serving their unique health and well-being needs. Up for the challenge of a lifetime? Join a team of the best and the brightest to find bold new ways to proactively improve the health and quality of life of these 9 million customers. You'll find a wealth of dynamic opportunities to grow and develop as we work together to heal and strengthen our health care system. Ready? It's time to do your life's best work.SM

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.