RN, HEDIS Quality Manager - North and Central Texas - Hybrid

UnitedHealth Group•San Antonio, TX

20d•$72,800 - $130,000•Hybrid

About The Position

The Quality Manager drives consistent implementation of programs designed to help the market achieve a minimum four-star quality rating. The role supports contracted physician networks in understanding and advancing the vision for improving healthcare delivery for seniors, while supporting the financial viability of the market’s HEDIS/Star program and quality of care for members. The position requires strategic planning and analysis, knowledge of HEDIS and coding, management capabilities, strong communication, and the ability to develop action plans and advance processes amid complex issues and interdependencies. It also facilitates resolution of issues that remain after standard processes are followed. The manager leads the market quality staff and is accountable for the market’s HEDIS/Star results for contracted physicians. The role works with physician groups, providers, and internal partners to resolve concerns, identify barriers, support education, and advance quality initiatives. The position is hybrid and covers North and Central Texas, with travel based on business needs.

Requirements

Registered Nurse with an active, unrestricted license to practice in the state of employment.
At least 5 years of related experience in Quality/HEDIS/CMS Stars, ICD-10/CPT/CPT II coding knowledge, and Provider Relations.
At least 2 years of supervisory experience.
Working knowledge of Medicare quality operations, including HEDIS, Stars, coding, and Medicare Advantage.
Knowledge of state and federal laws relating to Medicare.
Ability and willingness to travel locally and non-locally as determined by business need.
Exceptional analytical and data representation expertise.
Advanced Microsoft Office skills, including proficiency in Excel.
Valid driver’s license, reliable transportation, and current automobile insurance; ability to travel up to 25% based on business needs.

Nice To Haves

Solid knowledge of clinical standards of care, preventive health, and STAR measures.
Project management experience.
Solid financial analytical background within Medicare Advantage plans, including Risk Adjustment/STARS calculation models.

Responsibilities

Manage Quality Coordinators and Clinical Quality Consultants (CQC) at I, II, and Senior levels, and oversee the success of the market’s HEDIS/Star results for contracted physicians.
Lead staff development, including hiring, training, coaching, and development.
Set objectives and provide training, skill development, and leadership to maximize staff performance and technical expertise.
Delegate, monitor, and control progress on HEDIS/Star metrics, initiatives and action plans, staff productivity, and administrative expenses.
Participate in developing and implementing systems and processes that support quality operations.
Maintain effective cross-functional relationships with medical, market, regional, clinic operations, and corporate teams.
Handle complex provider inquiries and problems, facilitate resolution, and maintain favorable provider relationships while protecting organizational interests.
Own the overall work process and provide constructive information to support physician partners in meeting initiatives.
Analyze data and collaborate with colleagues and business partners to identify potential root causes of issues.
Understand providers’ goals and strategies to facilitate analysis and resolution of their issues.
Work with internal stakeholders to identify provider obstacles and barriers and methods to remove them.
Communicate and advocate providers’ needs to internal stakeholders to drive solutions that meet HEDIS/Star goals.
Communicate industry and company information to providers through newsletters, emails, outreach calls, teleconferences, conferences, and on-site meetings.
Develop and coach staff to facilitate strategic business meetings with physician groups and their staff.
Guide, oversee, and ensure the competency of market quality staff.
Assist corporate and local education teams and provide input on tools used to educate quality staff and local provider support staff.
Ensure education objectives are met through formal and ad-hoc education.
Ensure quality staff respond to market operations and provider inquiries.
Facilitate provider discussions and help negotiate resolutions to escalated provider issues, determining when issues require further escalation.
Work with cross-functional leadership to eliminate duplication of efforts and member or provider abrasion.
Perform other related duties as assigned.