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

As the Women’s Health Quality Improvement (QI) Lead Clinical Practice Consultant (CPC), you will be responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures.

This position is full – time (40 hours / week) Monday – Friday. Employees are required to have flexibility to work any of our 8 – hour shift schedules during our normal business hours of 8am to 5pm.  It may be necessary, given the business need, to work occasional overtime. This position is a remote – based position with a home – based office.

If you are located in New Mexico, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

Ongoing management of provider practice and community education on state specific quality measures
Works with provider practices to develop action plans to drive quality improvement 
Educates providers and office staff on proper clinical documentation, coding, and billing practices, CMS mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
Analysis, review, and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements, and pay for performance initiatives
Serves as subject matter expert (SME) for Women’s Health Medicaid/Medicare HEDIS / CMS 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 Medicaid/Medicare HEDIS / CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve Medicaid/Medicare HEDIS / CMS Measure rates
Identifies patient care opportunities and collaborates with physician practices to ensure appropriate member appointments and care
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
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
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

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: 

Current, unrestricted RN license in the State of NM
2+ years of Healthcare experience
2+ years of Medicare / Medicaid experience
Intermediate level proficiency in Microsoft Excel
Currently reside in New Mexico
Reliable transportation to travel to physician offices locally up to 10% of the time

Preferred Qualifications:

3+ years clinical experience in a physician practice, outpatient facility or a FQHC
2+ years of quality improvement experience
2+ years of HEDIS experience
Health insurance industry experience, including regulatory and compliance
Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, governing and regulatory agency requirements and the managed care industry
Proven ability to handle multiple tasks and competing priorities