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UnitedHealth Group Clinical Practice Quality Analyst – Telecommute in San Diego, CA in San Diego, California

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)

Position is responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. This role will be responsible for ongoing management of provider practice and community education on state specific quality measures. The Clinical Quality Analyst will work closely with the Quality Director to coordinate an interdisciplinary approach to increased provider performance. 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 Clinical Quality Analyst will focus on tasks that occur in accordance with the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare Services (CMS) or other requirements as applicable. This position will also be responsible for direction and guidance on provider-focused, clinical quality improvement and management programs. This 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 reports to the Quality Leadership of the Health Plan.

If you are located in San Diego, CA you will have the flexibility to telecommute* as you take on some tough challenges. This position will be home-based and will require travel up to 75% of the time in San Diego County.

Primary Responsibilities:

  • Leads data mining and analytic activities (70% of time) to gather HEDIS-related data. Uses data and findings to then plan and facilitate provider training (30% of time) and Quality Improvement programs with the goal of increasing performance rates for Clinical Quality programs such as HEDIS and CAHPS.

  • Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement

  • Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS/State Specific quality measures for provider and staff education during field visits

  • Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)

  • Plans and facilitates Quality Improvement meetings with the Provider network and individual provider practices and groups

  • 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

  • Utilizes multiple databases, EHRs, and platforms to access and download reports; collect, upload, index, and abstract medical records; and monitor HEDIS performance

  • Analyzes data and manipulates reports to develop custom reports for providers, HEDIS® performance reports, and Pay for Performance Programs

  • Develops data sets, charts, pivot tables, and graphs to track, monitor, and report effectiveness of Clinical Quality programs

  • 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

  • Conducts member outreach to provide education on care gaps and utilizes motivational interviewing techniques to encourage members to access care for needed services, coordinating scheduled visits with provider offices

  • Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director

  • 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

  • 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

  • Prepares educational materials for training providers and support staff in HEDIS measures, clinical transformation practices, care gap roster management, and population management techniques

  • Supports the plan in preparing member education materials, educational newsletters, and attending community events as needed

  • Participate in regulatory Quality Improvement Projects, implementing interventions and other monitoring activities

  • Supports the plan in monitoring effectiveness of member engagement programs and provider incentive programs. Escalates feedback or trends of concern to the Health Plan Quality Director

Required Qualifications:

  • Bachelor’s degree OR four years of equivalent experience OR current, unrestricted RN license in the state of California

  • 3+ years of health care, clinical or community based experience

  • 1+ year(s) of experience in Managed Care or Primary Practice setting, including regular interaction with Providers regarding Clinical Quality Improvement

  • Proficiency using a PC in a Windows environment, including Microsoft Word

  • Experience utilizing data base systems including reporting generation and analysis

  • Ability to Travel to physician offices locally up to 75% of the time in San Diego County

  • Access to reliable transportation

Preferred Qualifications:

  • Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements

  • 1+ year(s) experience in clinical setting or Federally Qualified Health Center

  • Experience making formal presentations to all levels of clinical staff

  • Experience facilitating meetings and developing trainings

  • Experience working in Medicaid and/or Medicare

  • Master’s degree in Public Health or related field

  • Multilingual

  • Account Management experience

Careers 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

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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: Quality, Clinical, HEDIS, NCQA, governing and regulatory, Medicare, Medicaid, MediCal, managed care, primary care, San Diego, CA, California, public health, account management, bachelor's degree, RN, registered nurse, FQHC, San Diego, SD, CA, California