Clinical Quality Nurse RN - Telecommute (Louisiana)

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 Quality RN is responsible for ongoing HEDIS collection and improvement activities at the health plan and reports 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. 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. 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, measurement (QI 13) 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

AmeriChoice is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system. If you're ready to help make health care work better for more people, you can make a historic impact on the future of health care at AmeriChoice.

We contract with states and other government agencies to provide care for over two million individuals. Working with physicians and other care providers, we ensure that our members obtain the care they need with a coordinated approach.

This enables us to break down barriers, which makes health care easier for our customers to manage. That takes a lot of time. It takes a lot of good ideas. Most of all - it takes an entire team of talent. Individuals with the tenacity and the dedication to make things work better for millions of people all over our country.

You can be a part of this team. You can put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered.

Required Qualifications:

• Clinical Registered Nurse with current, unrestricted licensure required


• 3+ years clinical experience


• Solid knowledge base of clinical standards of care and preventive health standards


• Reliable transportation, and the ability to travel to physician offices 90-100% of the time within the assigned territory, primarily in and around Alexandria, Louisiana areas


• Demonstrated ability to be self-directed with excellent time management skills and organizational skills


• Ability to evaluate medical records with attention to detail


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


• Demonstrated strong computer skills to include the ability to navigate a Windows environment, toggle between multiple screens, and work within MS Excel spreadsheets


• Proven ability to make business decisions within flexible guidelines


• Demonstrated excellent verbal and written communication skills including the ability to professionally interact with Physicians and their staffs as well as submit professional reports


• Proven ability to make professional presentations in front of committee and work group environments


• Telecommute within the state of Louisiana.


• Willing to travel distances to Providers offices of approximately 2 hours-No overnight travel
  

Preferred Qualifications:

• 2+ years of quality improvement experience, or other relevant experience


• Knowledge of HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry


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


• Would consider a Clinical Dietician --- registered in Louisiana.
  

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 14 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)