Clinical Practice Consultant - Field based Position (RN required)
UnitedHealth Group - Atlantic City, NJ

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The Clinical Practice Consultants are experienced RN's who are assigned practices with large panels that have members who are non compliant in HEDIS measures. They also coordinate activities with Provider Advocates and others to provide a comprehensive full spectrum of education and support to the practices. The Clinical Practice Consultants are responsible for ongoing HEDIS collection and improvement activities at the health plan and report to the Quality Management Leader.

Primary Responsibilities:
  • Coordinates and performs onsite medical record reviews at provider offices to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards, and where assigned investigation of quality of care and member complaints relative to quality of care and service

  • Support continuum of member care by identifying members in need of health education, case management, etc.

  • Educates providers and office staff on proper coding and billing practices, HEDIS and state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria

  • Solicit identification of barriers the office faces in providing care to members

  • Supports the HEDIS medical record chase to support optimum HEDIS and quality metric reporting

  • Supports quality improvement program studies requesting records from providers, maintaining databases, and researching to identify members' provider encounter history

  • Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned

  • Performs annual medical record evaluation, follow-up education, practitioner intervention as required

  • Enter documentation of findings in identified database

  • Generally works independently, under the supervision of the Quality Management leader

  • Participates in or coordinates with other department projects as needed

UnitedHealthcare, part of the UnitedHealth Group family of companies, is comprised of three specialized businesses dedicated to meeting the health care benefits needs of individuals and groups; all part of something greater, but each with a specialized focus:

UnitedHealthcare Employer & Individual works with individuals, small businesses and large multi-site employers to provide innovative, affordable benefits services.

UnitedHealthcare Medicare & Retirement is focused on serving Americans over the age of 50. It is the largest business dedicated to meeting the growing health and well-being needs of aging individuals in the nation, serving one in five Medicare beneficiaries through a comprehensive and diversified array of products and services through four industry-leading businesses.

UnitedHealthcare Community & State provides high-quality, personalized, public-sector health care programs that help local government agencies improve health outcomes for millions of children and low-income and disabled individuals at an affordable cost.

Together, we’re removing the barriers that keep people from receiving the kind of quality health care that makes a difference. We focus on Integrity, Compassion, Relationships, Innovation and Performance as we empower people to achieve better health and well-being.

Come grow and thrive in our culture of innovation and ideas. Because there is no opportunity greater than the quest to help people live healthier lives.
  • RN with active, unrestricted licensure in state of New Jersey

  • 3 or more years clinical experience

  • Previous HEDIS abstraction experience is strongly preferred.

  • Experience working in Medicaid and/or Medicare health care and insurance industry, including regulatory and compliance requirements

  • Level of proficiency with Microsoft Office applications including Word, Excel, Access and PowerPoint

  • Ability to travel to Providers' offices in service area
  • Strong organizational skills and ability to work both independently and with teams

  • Ability to evaluate medical records with attention to detail

  • Ability to interact with medical staff, peers, and internal company staff at all levels

  • Ability to make formal presentations in front of committee and work group environments

  • Must have reliable transportation.

  • Bilingual a plus.

Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.

UnitedHealth Group - 2 years ago - save job
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