Clinical Practice Consultant RN/LPN Reviewer for New York City
UnitedHealth Group - New York, NY

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There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)

This position is responsible for ongoing HEDIS collection and improvement activities at the health plan and reports to the Quality Management Leader.
  • 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, measurement 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/LPN with current licensure in New York
  • 3+ years clinical and/or HEDIS experience
  • 2+ years of quality improvement experience, or other relevant experience
  • Experience working in Medicaid and/or Medicare health care and insurance
  • Industry, including regulatory and compliance
  • Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency
  • Ability to travel to physician offices; valid state-specific driver's license and reliable vehicle
  • 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
  • Ability to use databases and prepare reports as needed
  • Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint
  • Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance and achieve targets
  • Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  • Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
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.

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When you work to better people’s lives, one of those lives will always be yours. We have modest goals: Improve the lives of...