Clinical Practice Consultant for New Castle and Kent Co, DE

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Position responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. Position responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse CPC 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.  The Registered Nurse CPC will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. Position responsible for direction and guidance on provider-focused, clinical quality improvement and management programs.   The 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, NCQA and other tools. Position reports to the Quality Leadership of the Health Plan.
 
Job Components:


Front Facing Practice Level Leadership
Targeted Quality Improvement
Gaps in Care Closure
Relationship Management, Internal and External
Community Engagement and Interaction
Provider and Practice Education, Quality Oriented Health Topics
 
Primary Responsibilities:

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
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
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
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
Documents and refers providers' non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer
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
Participates in or coordinates with other department projects as needed
Needs to works independently and within an integrated team in a highly matrixed environment
May do additional duties as assigned
 
 
This position requires training in the office for 3 weeks. There is an opportunity to work-at-home after the initial training. There are no weekends, nights, on-call or holiday work. This role will cover the entire state.
 
KEYWORDS:  RN, Health Care, Medicaid, Medicare, HEDIS, NCQA, Managed Care, Clinical, Work at Home, Newark, Delaware, DE, telecommute
 
 
 

Required Qualifications:

Current unrestricted RN licensure required in the state of operation
5+ years clinical experience
2+ years of quality improvement or medical record review experience 
Ability to make formal presentations within the context of their role
Ability to use databases and prepare reports as needed
Proficiency in software applications that include, but are not limited to, Microsoft Word,  and  Excel
Problem solving skills
Excellent verbal and written communication skills
 
Preferred Qualifications:

Experience working with Medicaid
Highly preferred 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
Proficiency in Power Point
Multilingual candidates
 
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.
 
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
Job Keywords: RN, Clinical experience, Clinical Practice Consultant, Medicaid, HEDIS, Newark, DE, Delaware