Clinical Practice Consultant

UnitedHealth Group • Lewiston, ME

231d • $71,600 - $140,600 • Remote

About The Position

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Clinical Practice Consultant (CPC) will be responsible for strategically developing clinically oriented provider and community-based partnerships, education, and action plans to increase quality scores based on HEDIS, NCQA, and state specific quality measures. This role will be responsible for ongoing management of provider practice quality measures. Through HEDIS documentation collection and review, monitoring, measuring, and reporting on key metrics, the Clinical Practice Consultant assists providers in meeting quality standards, state contractual requirements and pay for performance initiatives. If you reside in Idaho, you will have the flexibility to work remotely as you take on some tough challenges.

Requirements

• 3+ years of Clinical experience in a physician practice, outpatient facility or a FQHC
• 2+ years of quality improvement experience
• 2+ years of Medicare / Medicaid experience
• Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint
• Reliable transportation to travel to physician offices locally up to 75% of the time
• Resident of Idaho

Nice To Haves

• Current, unrestricted RN license in the State of ID
• 2+ years of HEDIS experience
• Health insurance industry experience, including regulatory and compliance
• Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, governing and regulatory agency requirements and the managed care industry

Responsibilities

• Ongoing management of provider practice and community education on HEDIS, NCQA, and state specific quality measures
• Work with provider practices to develop action plans to drive quality improvement
• Educate 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
• Analysis, review, and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements, and pay for performance initiatives
• Serve as subject matter expert (SME) for assigned Medicaid/Medicare HEDIS / CMS measures, preventive health topics; lead efforts with clinical team to research and design educational materials for use in practitioner offices; serve as liaison with key vendors supporting Medicaid/Medicare HEDIS / CMS Measures; consult with vendors to design and implement initiatives to innovate and then improve Medicaid/Medicare HEDIS / CMS Measure rates
• Identify patient care opportunities and collaborate with physician practices to ensure appropriate member appointments and care
• Coordinate and perform 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
• Investigate 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
• Document and refer 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
• Other duties as assigned

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities