Job Description
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. This position is responsible for ongoing HEDIS collection and improvement activities at the health plan and reports to the Quality Management Leader.
If you reside near Bexar, Kendall, Bandera, Medina Atascosa, Wilson, Guadalupe, Comal, Counties, TX, you will enjoy the flexibility to telecommute as you take on some tough challenges. This position will require travel up to 75% of the time to providers offices. Responsibilities • Coordinates and performs onsite medical record reviews at provider offices to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards and where assigned investigation of quality of care and member complaints relative to quality of care and service • Support continuum of member care by identifying members in need of health education, case management, etc • Educates providers and office staff on proper coding and billing practices, HEDIS and state-mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria • Solicit identification of barriers the office faces in providing care to members • Supports the HEDIS medical record chase to support optimum HEDIS and quality metric reporting • Supports quality improvement program studies requesting records from providers, maintaining databases and researching to identify members' provider encounter history • Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education and disparity programs, as assigned • Performs annual medical record evaluation, follow-up education, practitioner intervention, measurement (QI 13) as required • Enter documentation of findings in identified database • Generally works independently, under the supervision of the Quality Management leader • Participates in or coordinates with other department projects as needed Requirements • Current unrestricted RN licensure in Texas • 5+ years of clinical experience in any setting • 2+ years of quality improvement experience (chart review, compliance, HEDIS, investigation, utilization review, etc.) • 2+ years of experience reviewing and evaluating medical records with attention to detail • 2+ years of experience working in Medicaid/Medicare health care and insurance industry, including regulatory and compliance requirements • Intermediate level of proficiency in software applications that include, bolthires Word, Excel, bolthires Outlook • Ability to make formal presentations in front of committee and work group environments • Access to reliable transportation that will enable you to travel to client or patient sites within a designated area & valid US driver's license Nice-to-haves • Bachelor's degree • Experience in complex populations • Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements and the managed care industry • Bilingual - English / Spanish • Ability to interact with medical staff, peers and internal company staff at all levels Benefits • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays • Medical Plan options along with participation in a Health Spending Account or a Health Saving account • Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage • 401(k) Savings Plan, Employee Stock Purchase Plan • Education Reimbursement • Employee Discounts • Employee Assistance Program • Employee Referral Bonus Program • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.) Apply tot his job