Remote Sr Clinical Quality RN Call Center, TX

WellMed

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Requisition Number: 2197839
Job Category: Nursing
Primary Location: San Antonio, TX
(Remote considered)

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.   

The WellMed Quality Clinical Programs team supports WellMed Medical Management by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close STARS/HEDIS gaps in care, including medication adherence, care for older adults, medication reconciliation post discharge, A1c, Blood pressure and statin therapy in patients with diabetes and cardiovascular disease. Our interdisciplinary service delivery team is comprised of Clinical Pharmacists, Registered Nurses, Licensed Vocational Nurses, and Social Workers.

The Registered Nurse will report into the Manager of Clinical Programs. The Registered Nurse will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. In addition, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work to support the hours of operation of the business (Mon-Fri 8am-6pm Central and Saturday 8am-5pm Central).

If you are located in Nursing Compact states, you will have the flexibility to work remotely* as you take on some tough challenges.

  

Primary Responsibilities: 

  • Strictly adheres to department’s metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests
  • Primarily to make outbound calls and will help manage the inbound call queue from patients, patient representatives, providers and other medical staff, while strictly adhering to established protocols and scripting
  • Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services
  • Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments
  • Educate patients on health conditions and necessity of routine screening and assisting with appointment scheduling (A1c, Controlling Blood Pressure, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.)
  • Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided
  • Review available medical records for core measures to submit for closure of HEDIS/STARS measures
  • Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs, (Pharmacy assistance programs, meals on wheels, LIS)
  • Document thoroughly all calls and actions taken within core systems
  • Performs all other related duties as assigned

  

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 Registered Nurse eLNC Compact licensure in state of residency
  • 5+ years of RN experience, including experience in a managed care setting
  • 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role.
  • 2+ years of Call Center experience
  • 2+ years of experience with data analysis and/or quality chart reviews. Must be able to review paper and electronic medical records and charts
  • Demonstrated proficiency with Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets. Must be proficient in Excel

 

Preferred Qualifications:

  • Undergraduate degree
  • Billing and CPT coding experience
  • Clinical data abstraction experience
  • Solid knowledge of the Medicare HEDIS/Stars measures
  • Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
  • Proven ability to manage multiple complex, concurrent projects
  • Proven adaptable to change
  • Proven good business acumen, especially as it relates to Medicare
  • Proven excellent written and verbal communication and relationship building skills
  • Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
  • Proven excellent customer service skills and communication skills
  • Bilingual with preference given to Spanish and Vietnamese

  

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