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Act as a consultant between the health plan and the delegates, using information from statistical analysis, and other sources to affect increased efficiency and effectiveness in clinical delegation activities as defined by the applicable delegation agreement. This position has five key objectives:
Systemically or at member level, support delegate activities designed to improve clinical outcomes in an efficient and effective manner
Consult in the development and monitoring of targeted programs and strategies designed to achieve appropriate utilization and quality goals across the care continuum
Consult with the delegate and UHC partners to identify and implement strategies to optimize affordability and quality priorities to improve population health
Collaborate with UHC partners to implement improvement strategies to simplify and streamline processes
Consult with the delegate regarding systemic, or specific member level process improvement activities in the management of catastrophic, disease and population health management and escalate to UHG partners for resolution (e.g. UHN, Optum, NICM)
This position may report to the Director, Medical Management Clinical Operations or the Vice President, Medical Management Clinical Operations, or Chief Medical Officer of market.
Monitors monthly and quarterly UM performance and quarterly quality performance of assigned delegates
Analyzes data and interprets results to assess the performance of the delegate to ensure alignment with utilization and quality goals of the business
Contributes to Quality Team strategies to improve HEDIS, STARs, and other quality metrics
Contributes to identifying and implementing Affordability strategies to address market adverse trends
Identifies internal and delegate strategies for improvement including the identification of specific outcomes and metrics to monitor progress to a goal
Provides feedback and makes recommendations about process improvement, in coordination with
the Chief Medical Officer, to clinical delegates; presents to delegate workgroups, delegates, and leadership
Provides consulting to clinical delegates on a variety of topics including utilization management, case management, disease management programs, and operational processes, including sharing best practices
As necessary, oversights and follows clinical delegates on potential long stay, or catastrophic inpatient case management cases and advises Chief Medical Officer if inefficiencies are identified. Appropriately documents clinical records within UHC medical management systems as needed.
Acts as the liaison for clinical issues related to performance of delegated responsibilities
Has knowledge of delegation agreements, local market data, and other data utilized to develop strategies for process improvement
As necessary, collaborates with UHC clinical teams to act as a subject matter expert in the development of delegate process improvement initiatives including determining the root cause of issues, proposing solutions, and overseeing recommended changes
Presents findings at Joint Operating Committee (JOC) meetings and in Medical Management meetings to the delegate's Medical Directorship and other clinical leaders
Attends and contributes in regular internal meetings with Clinical, Quality, Health Plan, Network Management, Sales and other staff, as appropriate
Establishes and maintains strong working relationships with key internal and external constituencies
Current Registered Nurse license as required by applicable state licensure board
A minimum of 5 plus years of relevant work experience in the Medical Group/IPA or Health Plan setting for concurrent review, prior authorizations, case management, referral management, retrospective review and discharge planning in hospital, ambulatory and ancillary settings.
Strong clinical program development and program management skills, including
Proven ability to identify operational process gaps and clinical gaps in care
Demonstrated knowledge of root cause analysis and solution development
The ability to gain acceptance from others of a need, plan or idea to achieve a mutually beneficial outcome
Proficiency in ICD-CM, CPT, DRG and HCPCS coding
Advanced proficiency with Microsoft Excel, Word, and Access
Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others
Demonstrated ability to present to and/or train large groups. Advanced proficiency in industry knowledge. Ability to develop presentation materials for executive level meetings, and lead discussion to gain action on identified opportunities to improve utilization or quality performance
Travel is frequent, up to 50% of the month with travel to local, regional Medical Groups/IPAs. Associate is required to reside within the assigned market of responsibility, which must be within the state of CA.
Financial assistance will not be provided for relocation.
Master's degree and or managed care experience at the management level
Demonstrated effectiveness in performing statistical analysis and leading presentation of utilization management data, including one-on-one meetings with medical directors/physician leaders
Acute inpatient experience
Clinical operations experience in the Medical Group/IPA/Hospital and health plan settings
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: Medical Management Consultant, Clinical Consultant, RN, Registered Nurse, Delegated, Managed Care Consultant, Clinic Administrator, Utilization Review, Ambulatory, Concurrent Review, Prior Authorization, Retrospective Review, Discharge Planning, Cypress, CA, California, Work at Home
Unitedhealth Group Inc.