Clinical Quality Nurse RN - Field based in Cleveland, OH

• 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.


• Where assigned, investigates quality of care and member complaints relative to quality of care and service.


• Supports 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.


• Enters documentation of findings in identified database.


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

• Active, licensed RN in the State of Ohio


• Minimum 3 years clinical experience  as an RN


• Minimum 1 year experience HEDIS data collection

• MS Office products proficiency to include Word and Excel


• CPHQ


• Experience with NCQA, Medicaid and/or commercial regulatory requirements


• Experience with Medicare

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 17 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can 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.