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The Clinical Quality Consultant (CQC) drive clinical relationships and engagement with account management, quality registered nurses, physician practices, members, and pharmacies while partnering internally (with areas such as Network contract ACO managers, Health Care Economics and Analytics, Medical Directors, Reporting, Health Plan market leaders) with a goal of improving health, well-being, quality, and practice performance while reducing medical costs. Positions are accountable for the full range of clinical practice performance which may include but is not limited to improvement on HEDIS and STARs gap closure, coding accuracy, facilitating effective education, and reporting, effective super utilizer engagement (e.g., members with complex and/or chronic conditions), and proactively identifying performance improvement opportunities using data analytics, technology, workflow changes and clinical support. These roles develop comprehensive, provider-specific plans to increase their physician practice performance, reduce readmissions and improve their outcomes.
Primary Responsibilities:
Provide analytical interpretation of HEDIS, Stars, Pharmacy, CAHPS and HOS reporting, supplemental data submissions, EMR sweep reporting, Vendor performance reporting, Lab Data Pulls, including executive summaries to account management and provider groups
Participate in weekly, Monthly, Bi-monthly, Quarterly and/or Annual business Review meetings related to STAR activities, which summarize provider group performance and market performance, as requested by, or required by Quality or Local leadership
Evaluate provider group/provider office structure and characteristics, operations, and personnel to identify the most effective approaches and strategies in improving STAR measures
Perform chart review and data abstraction
Maintain effective and ongoing communications and relationship with assigned provider groups and account managers
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
1+ years Healthcare/Health Plan/HEDIS/STARS experience and/or knowledge
Experienced in medical record review
Demonstrated experience with decision-making., Experience should include in-depth, hands-on exposure in dealing with multiple constituents and customers
Knowledge of managed care requirements related to clinical quality and provider relations
Knowledge and application of continuous quality improvement concepts e.g., PDSA
Basic knowledge of Microsoft Office applications, including Word, Excel, and Outlook
Demonstrated success working in dynamic, fast-paced environment
Proven ability to assist with focusing activities on a strategic direction to achieve targets
Proven excellent time management and prioritization skills
Proven excellent verbal and written communication skills
Proven solid relationship building skills; ability to interact with providers, medical staff, peers, and internal company staff at all levels
Proven solid problem-solving skills and ability to analyze problems, draw relevant conclusions, develop, and implement appropriate plan of action
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.