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Position in this function is responsible for strategically developing clinically oriented provider and community-based partnerships in order to increase quality scores based on state specific quality measures. Position responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse CPC will work closely with the quality director to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. The Clinical Practice Consultant will focus on tasks that occur in accordance with State, CMS, or other requirements as applicable. Position responsible for direction and guidance on provider-focused, clinical quality improvement and management programs. The role assists contracted providers with analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS, NCQA and other tools. Position reports to the Quality Leadership of the Health Plan.

Primary Responsibilities:

• Front Facing Practice Level Leadership
• Targeted Quality Improvement
• Gaps in Care Closure
• Relationship Management, Internal and External
• Community Engagement and Interaction
• Provider and Practice Education, Quality Oriented Health Topics
• Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
• Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS / State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating, and facilitating on a local level)
• Serves as subject matter expert (SME) for assigned HEDIS / State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS / State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates
• Supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection, or for other focus studies as directed by the Plan Quality Director
• Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases, and researching to identify members' encounter history
• Participates, coordinates, and/or represents the Health Plan at community-based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned.
• Identifies population-based member barriers to care and works to identify local level strategies to overcome barriers and close clinical gaps in care
• Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
• Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
• Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion
• Based on medical record audit findings, provides follow-up education, practitioner intervention, and measurement as needed to drive quality improvement
• Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria
• Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy
• Documents and refers providers' non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer
• Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications
• Participates in or coordinates with other department projects as needed
• Needs to work independently and within an integrated team in a highly matrixed environment
• May do additional 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:

• Bachelor's degree in Science or equivalent work experience
• Current MI unrestricted license Registered Nurse
• 5+ years of clinical experience, or other relevant experience (clinical quality)
• Intermediate level Microsoft office
• Willing or ability to travel to physician offices locally up to 25% of their time

Preferred Qualifications:

• Master's degree
• 2+ years of quality improvement experience (chart review, compliance, HEDIS, investigation, etc.)
• Health care and insurance industry experience, including regulatory and compliance
• Michigan Medicaid experience
• 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
• Medical Coding knowledge / training
• Proven presentation skills (WebEx, Power Point)

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.

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.