Requisition Number: 2226103
Job Category: Nursing
Primary Location: Gainesville, GA
(Remote considered)
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The Clinical Practice Performance Consultant is responsible for program implementation and provider performance management which is tracked by designated provider metrics, inclusive minimally of 4 STAR gap closure and coding accuracy. The person in this role is expected to work directly with care providers to build relationships, ensure effective clinical education and reporting, proactively identify performance improvement opportunities through analysis and discussion with subject matter experts; and influence provider behavior to achieve needed results. The person will review charts (paper and electronic – EMR), look for gaps in care, perform telephonic assessments for preventative screenings and/or HEDIS gaps in care, help coordinate doctor appointments, make follow-up calls to members after appointments, and assist our members in overall wellness and prevention. Work is primarily performed at physician practices on a daily basis. This position does not entail any direct member care* nor does any case management occur. (*with the exception of participating in health fairs and/or health screenings where member contact could occur).
Hours: Monday – Friday – 8 AM – 5 PM EST
You’ll enjoy the flexibility to telecommute* from anywhere within in Georgia as you take on some tough challenges.
Primary Responsibilities:
- Functioning independently, travel across assigned territory to meet with providers to discuss Optum tools and programs focused on improving the quality of care for Medicare Advantage Members
- Execute applicable provider incentive programs for health plan
- Assist in the review of medical records to highlight Star opportunities for the medical staff
- Activities include data collection, data entry, quality monitoring, upload of images, and chart collection activities
- May conduct telephonic member needs assessments according to state and national guidelines, policies, procedures, and protocols
- Interact with members via telephone; Schedule appointments, Follow-up calls to assess understanding of services, answer questions and ascertain that additional procedures have been completed that relate to preventative health screenings or HEDIS gaps in care
- Review member charts prior to a physician appointment and create alerts/triggers to highlight Star opportunities for the practice
- Provides education to members regarding health care needs and available services related to preventative health screenings or HEDIS gaps in care
- Works to facilitate member compliance with their appointments, screenings, medications and/or action plans to complete open care opportunities/HEDIS gaps in care
- Identifies barriers for compliance in preventative health screenings or HEDIS gaps in care and communicates with members and providers to formulate action plan to address
- Establish positive, long-term, consultative relationships with physicians, medical groups, and pharmacies
- Develop comprehensive, provider-specific plans to increase their HEDIS performance and improve their outcomes
- Provides care coordination through physician practices for members to improve clinical quality and clinical documentation
- Provide ongoing strategic recommendations, training and coaching to provider groups on program implementation and barrier resolution
- Act as lead to pull necessary internal resources together in order to provide appropriate, effective provider education, coaching and consultation. Training will include Stars measures (HEDIS/CAHPS/HOS/med adherence), and Optum program administration, use of plan tools, reports and systems
- Provide reporting to health plan leadership on progress of overall performance, gap closure, and use of virtual administrative resource
- Provide suggestions and feedback to Optum and health plan
- Collaborates for the PPM (Practice Performance Manager) to drive strategies and support practice
- Other duties, as assigned
- Includes up to 75% local travel
What are the reasons to consider working for UnitedHealth Group? Put it all together – competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:
- Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
- Medical Plan options along with participation in a Health Spending Account or a Health Saving account
- Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
- 401(k) Savings Plan, Employee Stock Purchase Plan
- Education Reimbursement
- Employee Discounts
- Employee Assistance Program
- Employee Referral Bonus Program
- Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
- More information can be downloaded at: http://uhg.hr/uhgbenefits
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:
- Current, unrestricted RN license in the State the staff member resides in as well as any state member outreach is performed
- 3+ years of clinical experience in a hospital, acute care, home health, direct care or case management
- Intermediate level of proficiency with MS Office including; Excel, Outlook, and PowerPoint skills
- Reliable transportation, valid and unrestricted driver’s license, proof of insurance and ability to travel to provider offices or other locations within service delivery area (NE Atlanta Regional Area)
- Must live within the NE Atlanta GA regional area to be eligible for consideration
- Must be willing/able to travel approximately 75% of the time in the assigned regional area (NE Atlanta GA) as business needs dictate
Preferred Qualifications:
- Bachelor of Science in Nursing
- Case Management experience including Certification in Case Management
- 1+ year of STARs experience
- Experience with quality or quality assurance
- Experience with HEDIS and EMR (electronic medical records)
- Consulting experience
- Solid knowledge of the Medicare market
- Knowledge base of clinical standards of care, preventive health, and Stars measures
- Experience in managed care working with network and provider relations/contracting
- Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
- Solid communication and presentation skills
- Solid relationship building skills with clinical and non-clinical personnel
- Solid financial analytical background within Medicare Advantage plans (Risk Adjustment/STARS Calculation models)
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.