[Hiring] Sr Clinical Quality Registered Nurse @UnitedHealth Group

Role Description

The Clinical Performance Quality (CPQ) Pharmacy Operations team supports Optum’s Care Delivery Organizations by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close Medicare STARS/HEDIS gaps in care, including:

• Medication adherence
• Care for older adults
• Medication reconciliation post discharge
• A1c management
• Blood pressure management
• Statin therapy in patients with diabetes and cardiovascular disease

The Registered Nurse will report into the Director of Clinical Pharmacy and will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. Additionally, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work to support the hours of operation of the business (Mon-Fri 9am-6pm Central).

If you are located in a Compact State, you will have the flexibility to work remotely* as you take on some tough challenges. Hours are Monday through Friday 8AM - 5PM within your local time zone.

Primary Responsibilities:

• Strictly adheres to department’s metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests.
• Primarily to make outbound calls and will help manage the inbound call queue from patients, patient representatives, providers, and other medical staff, while strictly adhering to established protocols and scripting.
• Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services.
• Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments.
• Educate patients on health conditions and necessity of routine screening and assisting with appointment scheduling (A1c, Controlling Blood Pressure, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.).
• Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided.
• Review available medical records for core measures to submit for closure of HEDIS/STARS measures.
• Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs.
• Document thoroughly all calls and actions taken within core systems.
• Performs all other related duties as assigned.

Qualifications

• Active, unrestricted Registered Nurse eLNC Compact licensure in state of residency.
• Currently have or be able to obtain additional RN licensure in one or more of the following states: California, Connecticut, Nevada, New York, Oregon.
• 5+ years of RN experience, including experience in a managed care setting.
• 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role.
• 2+ years of experience with data analysis and/or quality chart reviews. Must be able to review paper and electronic medical records and charts.
• 1+ years of Call Center experience.
• Experience using Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets. Proficient in Excel.
• Solid knowledge of the Medicare HEDIS/Stars measures.
• Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels.
• Demonstrated ability to manage multiple complex, concurrent projects.
• Demonstrated excellent written and verbal communication and relationship building skills.
• Demonstrated solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action.
• Demonstrated excellent customer service skills and communication skills.

Preferred Qualifications

• Undergraduate degree, post graduate degree.
• Billing and CPT coding experience.
• Clinical data abstraction experience.
• Proven adaptable to change.
• Proven good business acumen, especially as it relates to Medicare.
• Bilingual with preference given to Spanish and Vietnamese.

Physical & Mental Requirements

• Ability to lift up to 25 pounds.
• Ability to sit for extended periods of time.
• Ability to use fine motor skills to operate office equipment and/or machinery.
• Ability to receive and comprehend instructions verbally and/or in writing.
• Ability to use logical reasoning for simple and complex problem solving.
• Ability to stand for extended periods of time.

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.