[Hiring] Clinical Practice Performance Consultant @UnitedHealth Group

Role Description

Position is responsible for strategically developing clinically oriented provider and community-based partnerships in order to increase HEDIS quality scores and state specific quality measures. This role will be responsible for ongoing management of provider practice quality measures and HEDIS medical record collection to support NCQA accreditation compliance.

The Clin Practice Perf Consultant will work closely with the Quality Field Operations manager to coordinate an interdisciplinary approach to increased provider performance in accordance with NCQA and State requirements. Focused provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level. Through HEDIS documentation collection and review, monitoring, measuring, and reporting on key metrics, the Clin Practice Perf Consultant assists providers in meeting quality standards, state contractual requirements and pay for performance initiatives.

Positions in this function drive clinical relationships and engagement with physician practices, members, and pharmacies while partnering internally 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)
• Proactively identifying performance improvement opportunities through the use of 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.

Generally work is self-directed and not prescribed. Works with less structured, more complex issues. Serves as a resource to others.

Primary Responsibilities

• Serves as subject matter expert (SME) for assigned HEDIS/State 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/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State Measure rates.
• Participates, coordinates, and/or represents the Health Plan at community-based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned.
• Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care.
• Reports individual member quality of care concerns or trends of concern to the Quality Manager.
• 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.
• 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.
• 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, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement.
• Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy.
• 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 state specific measures and technical specifications.

Qualifications

• Current unrestricted LPN or RN licensure required in the state of Maryland or the ability to obtain licensure for the state of Maryland.
• 5+ years clinical experience.
• 2+ years of quality improvement experience.
• Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint.
• Travel to physician offices locally up to 50% of their time.

Preferred Qualifications

• Experience working in Medicaid and/or Medicare.
• Health care and insurance industry experience, including regulatory and compliance.
• 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.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Salary

The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.