Clinical Practice Consultant - Las Vegas, NV

UnitedHealth Group•Las Vegas, NV

9h•Onsite

About The Position

The Clinical Practice Consultant will be 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 quality measures. The Clinical Practice Consultant will work closely with quality leadership to coordinate an interdisciplinary approach to increase 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 Clinical Practice Consultant 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. This role requires up to 75%25 travel locally to provider offices throughout Clark County.

Requirements

Current and unrestricted RN license in the state of Nevada
2+ years of clinical experience
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
Proficient in Microsoft Excel, Word, and PowerPoint
Ability to travel locally up to 75%25 of the time to physician offices (Las Vegas area)

Nice To Haves

Bachelor’s degree
Health care and insurance industry experience, including regulatory and compliance
Previous quality or process improvement experience
Previous general medicine, critical care, cardiology, oncology and pediatric experience
Ability to communicate verbally and through written communication
Ability to analyze, summarize and present data and reports to committees in both verbal and written formats
Ability to work in a team environment
Bilingual Spanish

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
Provides 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, leads efforts with clinical and analytical teams 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 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 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 Quality Manager
Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and documentation practices, compliance with quality metrics, compliance with service delivery and quality standards. May also be required to conduct additional QI audits through medical record review
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 and coding practices, state-mandated quality metrics specifications and medical record review criteria
Supports continuum of member care by identifying members in need of health education and/or services (interdisciplinary consultation) and refers Providers to the appropriate internal departments for follow through
Documents and refers providers’ non-clinical/service issues to the appropriate internal parties, to include but not limited to Provider Relations, etc.
Works with Providers on standards of care, and advises Providers on established clinical practice guidelines, and appropriate documentation and coding 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 Quality Leadership
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