Healthcare Physician Practice Consultant / Medical File Review Nurse - New York

This role is responsible for provider performance management which is tracked by designated provider metrics, inclusive minimally of 4 STAR gap closure and coding accuracy.  The person in this role is expected to work directly with care providers to build relationships, ensure effective education and reporting, and to proactively identify performance improvement opportunities through analysis and discussion with subject matter experts.

Responsibilities:

- With overall ownership of the physician practice performance with a focus on STARs and gap closure, evaluate each practice based on current performance and establish goals unique to each practice.
- Dedicated to M&R business with dotted line to RVP and responsible for reporting practice performance results to M&R leadership.
- Ensure all applicable groups are performing at 4 stars or higher.
- Evaluate practice office operations with a focus on identifying barriers to achieving targeted outcomes.  Responsible for developing solution-based user friendly initiatives to support practice success.
- Act as lead to pull necessary internal resources together (UHN/Advocates/physician service, clinical & Optum, M&R local leadership) in order to provide appropriate level of provider education and consultation.
- Evaluate and provide feedback to improve performance of provider support personnel, inclusive of clinical and non-clinical personnel.
- Coordinate and lead JOC meetings with provider groups with regular frequency to drive continual process improvement to achieve above mentioned targeted goals.
- Coordinate onsite training focusing on STARs measures (HEDIS/CAHPS/HOS/med adherence), Optum Programs (HQPAF, Chart Audits...) and ensure provider understands incentive opportunities and receives ongoing feedback and report cards designed to motivate and optimize provider incentive payouts.
- Ensure providers are aware of Plan sponsored initiatives (Member Rewards, Hi Health Innovation, vision, fitness, Renew, Housecalls) designed to assist and empower members in closing gaps.
- Identify opportunities for provider and Plan to join forces in achieving targets, such as sponsorship of wellness day, co-branding, etc.
- Ensure all claims based issues are triaged to the appropriate party for claims analysis and “fix”.  Ensure timely resolution of all issues brought forth. 
- Coordinate Capitated / ACP provider performance results with internal ACP team.

Job Keywords:  Healthcare, Managed Care, RN, registered nurse, nurse practitioner, RPN, Medical File Review, Medical Coding