The ACO Quality and Transformation Consultant (QTC) is responsible for the ongoing management of Quality Initiatives with physician practices participating in UnitedHealthcare's (UHC) Accountable Care Organizations (ACO). The selected candidate will be responsible for strategically developing clinically oriented partnerships with ACOs and their participating providers in order to increase quality scores based on state specific quality measures. This role will collaborate with matrix partners on ongoing management of provider practice and community education on state specific quality measures. You will work to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the ACO and provider levels, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. You will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. This role will analyze member care, trending quality compliance and create action plans and programs to ACO in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS and other tools.
Position reports to the Regional Director of ACO Clinical and Practice Transformation.
This is a field-based role with a home-based (telecommute, work at home) office. You will be spending approximately 50% to 75% of the time in the field within an assigned coverage area. Candidates must be willing to travel within Connecticut.
Serves as subject matter expert (SME) for assigned HEDIS/ CMS measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/CMS Measure rates
Identify patient care opportunities and collaborate with ACO's physician practices to ensure appropriate member appointments and care
Coordinates and performs 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
Investigates 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
Educates 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
Documents and refers 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
Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with CMS specific measures and technical specifications
Build and effectively maintain relationship with the practice leadership and key clinical influencers actively involved in quality.
Regularly facilitate efficient, effective quality improvement meetings with the practice to monitor, present, and discuss progress on the action plan and achievement in milestones
Bachelor's degree or equivalent relevant experience
3 years of clinical or administration experience in a physician practice
2 years of quality improvement experience to include but not limited to STARs and HEDIS
Experience working with Medicare
Experience in interpreting and utilizing data to drive change
Experience working with and collaborating successfully with senior level leadership
Demonstrated experience leading groups and strong presentation skills
Strong Microsoft Office Skills with Word, Excel and PowerPoint
Must have access to high speed internet for home office set up
Willingness to travel between 50 - 75% for face to face meetings (varies by market)
Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area (require valid driver's license)
Health care and insurance industry experience, including regulatory and compliance
Demonstrated experience implementing Clinical and Quality initiatives designed to help provider or hospital groups achieve large-scale quality goals
Experience preparing and presenting information to clinical and executive level leadership
Knowledge of one or more of: clinical standards of care, preventive health standards, governing and regulatory agency requirements, and the managed care industry
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)
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.
Job Keywords: RN, Registered Nurse, Nurse, Quality, ACO, HEDIS, STARs, Practice Administration, Provider Relations, Medicare, Clinical Practice Transformation, Implementation, Quality Improvement, Performance Improvement, Managed Care, Healthcare, Healthcare Analytics, Telecommute, Hartford, New Haven, CT, Connecticut, UnitedHealthcare, UHC
Unitedhealth Group Inc.