Sr. Clinical Quality Analyst - Telecommute in NJ

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)
Primary Responsibilities:


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

Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director

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

Supports Quality Improvement Projects (QIP) by identifying and collecting relevant data, monitors progress and analyzes outcomes. Updates QIP documentation regularly

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, to drive quality improvement

Documents and refers providers' non-clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database

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

Develop and implement improvement projects and using data to develop intervention strategies to improve outcomes

Required Qualifications:


Bachelor's degree or higher in a healthcare related field

3+ years clinical experience-hospital, community, or managed care

2+ years of experience in quality improvement, this includes developing and implementing performance improvement projects

2+years demonstrated analytical experience preferred using quality data i.e. develop intervention strategies to improve outcomes
Demonstrated ability of writing skills, i.e. Project Report Documents
2+years of Project Management experience
Critical and analytical thinking required
Role requires travel to physician offices locally up to 20% of their time
Preferred Qualifications:


Health care and insurance industry experience, including regulatory and compliance

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

Knowledge of Managed Long Term Services and Support (MLTSS) or Medicare experience

RN Licensure 
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)
 
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and 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.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
Job Keywords: Senior, Clinical, Quality, RN, Registered Nurse, healthcare, Edison, NJ, New Jersey, telecommute, telecommuter, telecommuting, remote
 
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