Sr Clinical Quality Registered Nurse - Call Center - Remote

UnitedHealth Group•Eden Prairie, MN

2d•Remote

About The Position

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Clinical Performance Quality (CPQ) Pharmacy Operations team supports Optum’s Care Delivery Organizations by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close Medicare STARS/HEDIS gaps in care, including medication adherence, care for older adults, medication reconciliation post discharge, A1c, Blood pressure and statin therapy in patient with diabetes and cardiovascular disease. Our interdisciplinary service delivery team is comprised of Pharmacists, Registered Nurses, Pharmacy Technicians, and Care Coordinators. The Registered Nurse will report into the Director of Clinical Pharmacy. The Registered Nurse will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. In addition, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work to support the hours of operation of the business (Mon-Fri 9am-6pm Central). If you are located in a Compact State, you will have the flexibility to work remotely as you take on some tough challenges. Hours are Monday through Friday 8AM - 5PM within your local time zone.

Requirements

Active, unrestricted Registered Nurse eLNC Compact licensure in state of residency
Currently have or be able to obtain additional RN licensure in one or more of the following states: California, Connecticut, Nevada, New York, Oregon
5+ years of RN experience, including experience in a managed care setting
2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role
2+ years of experience with data analysis and/or quality chart reviews. Must be able to review paper and electronic medical records and charts
1+ years of Call Center experience
Experience using Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets. Proficient in Excel
Solid knowledge of the Medicare HEDIS/Stars measures
Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
Demonstrated ability to manage multiple complex, concurrent projects
Demonstrated excellent written and verbal communication and relationship building skills
Demonstrated solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
Demonstrated excellent customer service skills and communication skills

Nice To Haves

Undergraduate degree, post graduate degree
Billing and CPT coding experience
Clinical data abstraction experience
Proven adaptable to change
Proven good business acumen, especially as it relates to Medicare
Bilingual with preference given to Spanish and Vietnamese

Responsibilities

Strictly adheres to department’s metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests
Primarily to make outbound calls and will help manage the inbound call queue from patients, patient representatives, providers, and other medical staff, while strictly adhering to established protocols and scripting
Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services
Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments
Educate patients on health conditions and necessity of routine screening and assisting with appointment scheduling (A1c, Controlling Blood Pressure, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.)
Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided
Review available medical records for core measures to submit for closure of HEDIS/STARS measures
Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs
Document thoroughly all calls and actions taken within core systems
Performs all other related duties as assigned