Position responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures and to complete DHCS facility site, medical record and physical accessibility reviews. Position responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse CPC / FSR will work closely with the quality director and other internal and external stakeholders to coordinate an interdisciplinary approach to increased provider performance and compliance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. The Registered Nurse CPC / FSR will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. Position responsible for direction and guidance on provider-focused, clinical quality improvement and management programs. The role assists contracted providers with analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS, NCQA and other tools. Position will be responsible for coordinating visits and any administrative functions associated with the site visits. This is a Telecommute role based in Sacramento, California and requires travel to physician offices up to 75% of the time. Primary Responsibilities:Complete Facility Site, Medical Record and Physical Accessibility Reviews Education and Engagement of Practice Level Leadership Targeted Quality Improvement Gaps in Care Closure Relationship Management, Internal and External Community Engagement and Interaction Provider and Practice Education, Quality Oriented Health Topics
Required Qualifications:Current unrestricted RN licensure required in the state of operation 5+ years clinical experience or other relevant experience DHCS Facility Site Reviewer Certification or ability to obtain within 12 monthsPreferred Qualifications:Bachelor's degree in Science or higher DHCS Master Facility Site Reviewer Certification 2+ years of quality improvement experience or other relevant experience Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing, regulatory agency and facility requirements and the managed care industry Experience working in Medicaid and / or Medicare Health care and insurance industry experience, including regulatory and compliance Experience communicating effectively with broad audience including Physicians, nurses, non-clinical office staff, and across the Health Plan Strong organizational skills and ability to work both independently and with teams Experience working in a collaborative environment with ability the to influence others and build strong professional relationships Experience with making formal presentations within the context of their role Experience using databases to input information and prepare reports as needed Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPointCareers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to 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: Auditor, HEDIS, CMS, NCQA, DHCS, Site Reviewer, Quality, Medicare, Medicaid, Provider, Sacramento, Los Angeles, CA, California
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.