Remote Hybrid Clinical Quality Analyst, KS

Optum

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Requisition Number: 2205907
Job Category: Medical & Clinical Operations
Primary Location: Overland Park, KS
(Remote considered)

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 to start Caring. Connecting. Growing together. 

Positions in this family include those responsible for functions in areas such as health services, clinical services and delivery of clinical care.

Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation. Conducts clinical quality audits and may also be responsible for NCQA requirements. Responsible for the reporting and analysis of member care quality and for the development of plans and programs to support continuous quality improvement using HEDIS and other tools.

General Job Profile:

  • Analyzes and investigates
  • Provides explanations and interpretations within area of expertise

If you are located in Overland Park, KS, you will have the flexibility to work remotely *, as well as work in the office as you take on some tough challenges.

Primary Responsibilities:

  • Uses pertinent data and facts to identify and solve a range of problems within area of expertise
  • Investigates non-standard requests and problems, with some assistance from others
  • Works exclusively within a specific knowledge area
  • Prioritizes and organizes own work to meet deadlines
  • Provides explanations and information to others on topics within area of expertise

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.

Years of post-high school education can be substituted/is equivalent to years of experience.

Required Qualifications:

  • Licensed Vocational/Professional Nurse
  • 3+ years of healthcare experience to include experience in a managed care setting
  • 3+ years of experience with data analysis/quality chart reviews. Must be able to review data and provide recommendations for improvement
  • Experienced using Microsoft office applications, including databases, word-processing, and excel spreadsheets

Values Based Competencies

Employee

  • Integrity Value: Act Ethically
    • Comply with Applicable Laws, Regulations and Policies
    • Demonstrate Integrity
  • Compassion Value: Focus on Customers
    • Identify and Exceed Customer Expectations
    • Improve the Customer Experience
  • Relationships Value: Act as a Team Player
    • Collaborate with Others
    • Demonstrate Diversity Awareness
    • Learn and Develop
  • Relationships Value: Communicate Effectively
    • Influence Others
    • Listen Actively
    • Speak and Write Clearly
  • Innovation Value: Support Change and Innovation
    • Contribute Innovative Ideas
    • Work Effectively in a Changing Environment
  • Performance Value: Make Fact-Based Decisions
    • Apply Business Knowledge
    • Use Sound Judgement
  • Performance Value: Deliver Quality Results
    • Drive for Results
    • Manage Time Effectively
    • Produce High-Quality Work

Functional Competencies:

Functional Competency & Description    Proficiency Level

  • CQL_Collect, Analyze, and Investigate Quality Data and/or Information   B)  Developing
    • Collect Quality data and/or information based on applicable standards, state/federal or other regulations, customer or consumer requests, internal requests, or project assignments
    • Identify appropriate sources for data or information either internally or externally and collect data/information Develop effective methods for data/information collection
    • Identify appropriate data platform or application (e.g., data bases, Intranet source, Internet source) and utilize to collect data or information
    • Investigate Quality problems identified and collect additional information to close gaps
    • Work cross functionally and coordinate with others internally or externally to gather information; overcome challenges to obtaining needed information
    • Mine data and/or information to identify inconsistencies, trends, other information needed, etc. (e.g., develop and/or run data queries)
    • Analyze and interpret data or information (e.g., clinical, administrative, Quality) to ensure they meet standards, are compliant and/or are accurate and complete
    • Provide explanations or updates when data/information (e.g., clinical, administrative) are not accurate or unclear
    • Explain the characteristics of the data/information (e.g., clinical, administrative) including any unique attributes
    • Identify Quality improvement or intervention opportunities and work cross-functionally to develop interventions or recommendations
  • CQL_Document and Report Quality Information B)  Developing
    • Develop or update work plans (e.g., annual work plan)
    • Develop or update program descriptions (e.g., annual program descriptions)
    • Develop program evaluations (e.g., annual program evaluation) -Develop, update, and/or review policies and procedures
    • Review results, conduct analyses (e.g., evaluate against goals/effectiveness of interventions over time), and prepare reports on findings
    • Follow regulations and internal or external protocols for communicating information or data
    • Utilize computer systems to identify and annotate information
    • Load completed information into relevant systems according to specifications
    • Develop an understanding of the intended audience and determine the best method to communicate data or information -Communicate Quality data or information in writing or verbally
    • Report results (e.g., quality improvement initiatives, audits) to committees, Board of Directors, external stakeholders, regulatory agencies, etc. and respond to questions or solicit feedback and input
  • CQL_Perform/Participate in Audits or Review Activities to Ensure Quality              B)  Developing
    • Develop understanding of customer requirements and/or expectations and anticipate needs to determine appropriate course of action
    • Develop audit or review processes (e.g., automated/technically driven)
    • Review relevant agreements (e.g., contractual, intersegment) and obtain clarification as necessary
    • Read and interpret standards/requirements and/or technical specifications (e.g., structure and process, CMS star ratings, , URAC, NCQA/HEDIS/ CAHPS/member satisfaction specifications, SNP)
    • Evaluate current processes, compare to relevant standards or specifications and identify gaps in compliance or performance
    • Perform/participate in assessments of the audit or review (e.g., interrater reliability of audit findings across auditors)
    • Work cross-functionally, making recommendations or clarifying information to assist in closing gaps that are identified or meeting customer expectations
    • Work with auditors or key stakeholders for review/approval of results
    • Develop and/or assist with corrective action plans based on audit findings or customer feedback
    • Review processes and performance against customer expectations to provide needed information or service
  • CQL_Manage Quality Projects or Work Objectives            B)  Developing
    • Define project scope and develop project plan
    • Identify and recruit appropriate staff to assist with projects as necessary
    • Coordinate with others to set appropriate deadlines when necessary
    • Collaborate with stakeholders for review, input, and/or approval at key milestones
    • Manage key relationships (e.g., vendors, stakeholders, regulatory bodies) to ensure milestones are achieved and performance objectives are met
    • Manage or actively participate in meetings (e.g., schedule, present, document meeting results, facilitate)
    • Provide information and feedback to project team with respect to achievement of objectives
    • Leverage clinical expertise to inform decision-making and program development
    • Track timeframes/deadlines and collect data or information within required timeframes
    • Identify, prioritize, and proactively communicate potential barriers or risks to key stakeholders
  • CQL_Provide Quality Information, Education or Training to Others            B)  Developing
    • Educate, motivate, and/or influence others (e.g., leadership, other stakeholders, including those for whom there is no direct line of authority) to understand the overall scope, overcome potential barriers, and engage in and commit to the process
    • Communicate and explain applicable standards (e.g., industry/performance) and/or technical specifications and identified gaps and/or changes in applicable standards
    • Develop educational materials (e.g., member, provider and/or staff materials)
    • Work with others to ensure messaging to members and/or providers is appropriate to the audience, complete/accurate, and compliant (e.g., with external/internal regulations and protocols)
    • Train others on relevant policies, rules, or regulations (e.g., appropriate release of data, handling protected health information) -Serve as a resource providing explanations and expertise (e.g., accreditation, providing information to others, satisfaction survey, interventions)

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy