Senior Clinical Quality RN (NCLEX) - San Juan, PR

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. 

The Sr. Clinical Quality Consultant (CQC) will drive consistency, efficient processes and share best practices, in a collaborative effort with the provider and large or complex groups, designed to facilitate a minimum 4 STAR quality performance.

The Sr CQC will participate in quality improvement initiatives, attend monthly or joint operating committee meetings, develop recommendations for quality remediation plans and create tools and databases to capture relevant data for each region. This position will work collaboratively with each regional/market team and their leadership in a matrix relationship.  This position may serve as the team lead for the clinical quality consultants in the assigned market and has responsibility for the network’s quality performance. 

This position is full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8 hour shift schedules during our normal business hours of 7:00am – 6:00pm AST. It may be necessary, given the business need, to work occasional overtime or weekends.  Our office is located in the Montehiedra area in San Juan.

Primary Responsibilities:

• Develop market business plans to motivate providers and large or complex group leadership to engage in improving Stars measures to be 4 STARS or higher
• Place outbound calls to members to ascertain information from the patient regarding HEDIS and Quality measures related to their care as well as obtain member information regarding any possible gaps in care
• Provide analytical interpretation of Stars and HEDIS reporting, including executive summaries to plan and provider groups
• Be the primary subject matter expert for all STARS related activities within their assigned market(s) working within a matrix relationship which includes Quality corporate operations and Regional/Market operations
• Lead or participate and present in weekly, Monthly, Bi-monthly, Quarterly and/or Annual business Review meetings related to STAR activities which summarize provider and large group performance and market performance as requested by or required by Quality or Regional leadership
• Analyze and evaluate provider and large group structure and characteristics, provider group/provider office operations and personnel to identify the most effective approaches and strategies
• Assist in developing of training and analytical materials for Stars and HEDIS
• Identify and assess decision makers and other key provider group personnel with a focus on identifying barriers to achieving targeted outcomes, focus communications and efforts accordingly
• Develop solution-based, user-friendly initiatives to support practice success
• Performs all other related duties as assigned

** ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION **

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• NCLEX Certification
• 3+ of healthcare experience, including experience in a managed care setting
• Experienced using Microsoft office applications, including databases, word-processing, and excel spreadsheets
• Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for his position)

Preferred Qualifications:

• Bachelor or higher degree
• RN License, current and unrestricted in Puerto Rico
• Experience in HEDIS/Star programs, preferably in a clinical quality consultant role
• Experience  in provider interactions, including provider education
• Experience with data analysis and/or quality chart reviews
• Experience influencing providers to change behavior and drive improvement in quality performance
• Experience in managed care working with network and provider relations
• Experience interacting with medical staff, peers, and internal company staff at all levels
• Experience solving process problems crossing multiple functional areas and business units
• Billing and CPT coding experience
• Call Center experience
• Clinical data abstraction experience
• Solid knowledge of the Medicare market and products
• Proven solid problem-solving skills: the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
• Proven excellent communication and customer service skills

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

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.