[Hiring] Senior Clinical Quality RN @UnitedHealth Group

Role Description

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 optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

We support providers who care for UnitedHealthcare (UHC) Medicaid and CHIP members across five counties in southeastern Pennsylvania: Philadelphia, Montgomery, Bucks, Chester, and Delaware. Our team includes a Clinical Quality Manager, a Quality Director, and a Quality Nurse. This role will serve as the second Quality Nurse on the team.

Our primary goal is to promote our local Pay‑for‑Performance program and support providers in achieving the highest possible incentive outcomes by meeting HEDIS® and state quality measures.

You’ll enjoy the flexibility to work remotely within Montgomery and surrounding counties as you take on some tough challenges.

Qualifications

• Registered Nurse licensure in the state of PA
• Experience in clinical quality, patient safety, risk management, or performance improvement
• Experience leading or facilitating performance improvement within scope
• Knowledge of HEDIS® measures technical specifications
• Familiarity with quality measurement tools, such as dashboards, scorecards, databases, or EHR reporting tools
• Intermediate proficiency in Microsoft Office applications, particularly Excel and PowerPoint
• Demonstrated solid documentation and organization skills
• Willingness to travel to community-based events for assigned groups up to 10%
• Driver’s License and access to reliable transportation

Requirements

• Oversee ongoing provider practice engagement and community education related to state specific quality measures
• Collaborate closely with the Quality Manager and Quality Director to coordinate an interdisciplinary approach that improves provider’s performance
• Serve as the primary resource for provider focused clinical quality improvement and management programs
• Educate providers and office staff on quality program requirements, including analysis of provider level outcomes, monitoring of key metrics, and support in meeting quality standards, contractual obligations, and pay for performance targets
• Ensure activities align with State, CMS, NCQA, and other regulatory requirements
• Support providers in evaluating member care, identifying care gaps, and developing action plans using evidence based guidelines and quality tools (HEDIS®, NCQA, CMS, state specifications)
• Conduct onsite medical record audits to assess coding, documentation, quality compliance, and service delivery standards
• Investigate documentation gaps or system issues impacting measure performance, provide feedback, and monitor resolution to completion
• Analyze quality data to identify trends, opportunities for structured data, and gaps in care at the provider and member levels
• Maintain care opportunity reports, track encounter history, and support quality related studies or initiatives as directed by the Health Plan
• Support medical record collection and abstraction processes for Pre Season (April-January), Hybrid (January-April), PAPM Maternity (April-July) and other review periods to optimize measurement and reporting
• Prepare and distribute reporting, and analytics related to care gaps, performance trends, and member outreach opportunities
• Lead targeted practice level quality improvement initiatives through clinical education and deployment of approved materials
• Assist 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
• Deliver training on documentation, coding, billing, state mandated quality metrics, profiling, pay for performance methodologies, and medical record review criteria
• Serve as subject matter expert (SME) for assigned HEDIS®/ State Measures, preventive health topics, and lead efforts with clinical team to research and design educational materials for use in practitioner offices
• Drive closure of open care opportunities, including preventive services, chronic condition management, and other quality measures through HEDIS® data collection
• Identify population level barriers to care and recommend evidence based strategies to close clinical gaps and improve outcomes
• Build and maintain solid relationships with internal and external stakeholders, including providers, practice staff, community organizations, and public health partners
• Document and escalate non clinical or service related provider concerns to appropriate departments
• Coordinate with other departments on projects and initiatives that intersect with quality performance, regulatory activities, or provider engagement
• Work independently and within a highly matrixed team environment, managing competing priorities while meeting deadlines
• Perform additional duties as assigned by Quality Leadership

Benefits

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

Application Deadline

This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.