Remote Sr Clinical Quality Nurse RN – Nebraska

Requisition Number: 2179306
Job Category: Nursing
Primary Location: Omaha, NE
(Remote considered)

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 and start doing your life’s best work.(sm) 

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

Primary Responsibilities: 

• Prepares Health Services state reports, quarterly and ad hoc, including data analysis
• Participates in EQRO and NCQA Audits (NCQA measures QI 7,8,9,10)
• May complete monthly chart audits on HRCM cases
• May lead or is instrumental in the following meetings: HQUM, ER PIP work group, Meetings with HSD and MD on high profile cases; UNMC, HRCM meetings, Top 5% member management, weekly MDR, Member Interdisciplinary conferences for KB and PDN members, participates in P&P meetings, involved in monthly mandatory state restrictive services conference calls
• Participates in the following work groups: Appeals and Grievances, Provider Satisfaction, Provider admin guide revamp, Lead Members, Sickle Cell Disease, CHF
• Maintains and builds relationships with all aspects of UHC such as: Interaction with Optum Services, BI, Appeals and Grievances, Compliance, Providers, Hospitals, Vendors and Members
• Develop and continue provider-oriented partnerships in order to increase quality compliance to approximately 180 provider groups
• Ongoing management of provider education on quality HEDIS measures
• Support providers who have signed a CP-PCPi agreement so that they can earn bonuses for helping UHC members become more engaged in their preventative healthcare needs
• Provider education regarding the quality improvement program, which involves reviewing HEDIS measures and gaps in care on the Patient Care Opportunity Report (PCOR)
• Review and monitor measures that are on the report with providers to assist in meeting quality standards, state contractual requirements, and performance incentives
• Lead efforts with clinical teams to provide educational materials on preventative health and chronic disease management to help implement initiatives to improve HEDIS quality measures and rates
• Educate providers on HEDIS quality measures that are reported as administrative or hybrid and how the data is collected and reported by possible billing codes and/or supplemental data
• Educate and support providers on the use of Practice Assist, which is a convenient tool that shares information with providers about their patients who are UHC members. This platform uses claim, lab, and pharmacy data to communicate which members have medical conditions for providers to evaluate
• Educate and support providers on the UHC PATH Reference Guide, which provides quality measure information specific to UHC members who are due to get preventative care and chronic disease management. This resource can help providers better understand the specifications for quality measures. They will see the tools used to address care opportunities, as well as how to report data and possible codes to use for billing
• Document all provider interactions and communications in IMPACT
• Send monthly emails to providers notifying them that their latest PCOR is available to view and manage in Practice Assist
• Troubleshoot, submit, and review ServiceNow tickets for technical issues within Practice Assist
• Provision new providers in PUMA to grant them access to Practice Assist
• Communicate frequently with the UHC Networking team to gather provider contact information from newly signed CP-PCPi agreements
• Participate in HEDIS Chart Chase operations, which includes provider outreaches in order to obtain the necessary medical records
• This process includes reviewing chart chase educational materials, documenting in rateLIFT and OnBase, updating spreadsheets, calling provider offices, faxing chart chase requests, and attending weekly QOI meetings and vendor meetings to receive updates on rates
• Developed provider education on the PPC and WCC measures in hopes to have better compliance in the future
• Additional duties as needed by Director or Associate Director of Medical Clinical Operations and/or Quality

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: 

• Active, unrestricted RN license in the state of residence
• 3+ years of clinical nursing experience
• Experience with presenting presentations and public speaking
• Intermediate to Advanced computer proficiency in Microsoft Word, Excel, Outlook, PowerPoint and Internet
• Willing or ability to travel up to 25%
• Reside in state of Nebraska

Preferred Qualifications: 

• 5+ years RN experience in performing UM, CM responsibilities working with the Medicaid population
• Experience with quality improvement initiatives
• Experience interfacing with Regulatory and State Govt. Officials
• Program development experience
• Data Analysis experience
• Utilization Review background
• Knowledge of Nebraska Administrative Code (NAC Manual)
• Demonstrated leadership capabilities

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