Practice Performance Manager - Buffalo, NY - Full-time / Part-time

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)
 
Position is responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. This role will be responsible for ongoing management of provider practice and community education on state specific quality measures.  You will work closely with the quality director to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives.  You will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. This position will also be responsible for direction and guidance on provider-focused, clinical quality improvement and management programs.   This role assists contracted providers with analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS and other tools. Position reports to the Quality Leadership of the Health Plan.
 
This is a field-based role with a home-based (telecommute, work at home) office.  You will be spending approximately 75% of the time in the field within an assigned coverage area. Candidates must be willing to travel within the Buffalo, NY area.
 
Primary Responsibilities:


Serves as subject matter expert (SME) for assigned HEDIS/ CMS 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/ CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/CMS Measure rates

Identify patient care opportunities and collaborate with physician practices to ensure appropriate member appointments and 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

Educates providers and office staff on proper clinical documentation, coding, and billing practices, CMS 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 CMS specific measures and technical specifications

Required Qualifications:

Current unrestricted RN/LPN licensure required
A minimum of 1 year clinical quality experience (i.e. STARs, HEDIS)
3 years clinical experience in a physician practice
Proficiency in software applications that include Microsoft Excel
Preferred Qualifications:

2+ years of quality improvement experience
Experience working in Medicare
Health care and insurance industry experience, including regulatory and compliance
Knowledge of one or more of: clinical standards of care, preventive health standards, governing and regulatory agency requirements, and the managed care industry
Multilingual candidates
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 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: 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:  RN, LPN, Registered Nurse, Nurse, Case Manager, Quality, Health Care, Medicaid, Medicare, HEDIS, NCQA, Managed Care, Clinical Practice Consultant , Clinical, Public Health, Physician Practice, Work at Home, Telecommute, Buffalo, NY, New York, UHG, UnitedHealth Group, UHC, UnitedHealthcare
 
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