Sr. Clinical Quality RN - Southfield, MI and Western, MI - Full-time / Part-time

There are two openings for this position.  One is based in our office in Southfield, MI and the other is home-based in western MI, preferably the Kalamazoo area. Both positions involve frequent visits to providers' offices in the area   

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• Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement


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• Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS/State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)


• Serves as subject matter expert (SME) for assigned HEDIS/State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State Measure rates


• Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned


• Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care


• Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards


• Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion


• Based on medical record audit findings, provides follow-up education, practitioner intervention, and measurement as needed to drive quality improvement


• Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria


• Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy


• Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications


• If required, supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection, or for other focus studies as directed by the Plan Quality Director


• Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases, and researching to identify members' encounter history

Please note above responsibilities section that there are two openings, one of which is office based in Southfield, MI and the other is home based in Kalamazoo, MI.  Both include travel by car to providers' offices in the area, up to 75% local travel.

• A current, unrestricted RN license in the state of MI


• 2+ years experience in quality, disease, utilization or case management


• Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA,  governing and regulatory agency requirements and/or  the managed care industry


• MS Office proficiency, Word required,  Excel a plus


• Must be a self-directed individual with excellent writing skills and ability to collaborate with a team


• Reliable transportation and the willingness/ability to travel throughout the region as needed

• BSN or higher degree


• HEDIS exposure


• Experience with process improvements


• A clinical background in managed care


• Experience working with providers

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 

Diversity creates a healthier atmosphere: 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.