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. This position will be covering the counties of Hidalgo and Cameron and surrounding areas and will require travel up to 75% of the time. 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, measurement (QI 13) 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
Required Qualifications: Bachelors degree in Science or equivalent work experience Current unrestricted RN licensure required in Texas 5+ years clinical experience in any setting (with at least 1 year of acute care) 2+ years of quality improvement experience (chart review, compliance, HEDIS, investigation, etc.) Experience working in Medicaid and / or Medicare health care and insurance industry, including regulatory and compliance requirements Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements and the managed care industry Access to reliable transportation that will enable you to travel to client and / or patient sites within a designated area Ability to make formal presentations in front of committee and work group environments Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft Outlook, and Internet browsers Preferred Qualifications: Bilingual - English / Spanish Masters degree Experience in complex populations-Pediatrics Ability to evaluate medical records with attention to detail Ability to interact with medical staff, peers and internal company staff at all levels Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work. (sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: RN, Registered Nurse, HEDIS, Quality, Compliance, Medicaid, provider, clinical data collection, Spanish, Harlingen, Brownsville, Texas, TX, McAllen
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.