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Sr. Clinical Practice Consultant - Monroe County, Western New York - NY

UnitedHealth Group

Monroe County, NY
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Job Details

Sr. Clinical Practice Consultant - Monroe County, Western New York - NY(Job Number:722330)

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)
Position 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 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.
Primary Responsibilities:
  • Serves as subject matter expert (SME) for assigned Medicaid HEDIS / CMS 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 Medicaid HEDIS / CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve Medicare HEDIS / CMS Measure rates
  • Identify patient care opportunities and collaborate with physician practices to ensure appropriate member appointments and care
  • 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
  • Educates providers and office staff on proper clinical documentation, coding and billing practices, CMS mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria, to drive quality improvement
  • Documents and refers providers' non-clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
  • Works with providers on standards of care, and advises providers on established clinical practice guidelines and appropriate documentation and billing consistent with CMS specific measures and technical specifications

Job Clinical Quality Management
Primary Location US-NY-Monroe County
Other Location 
Organization C&S Quality Management
Schedule Full-time
Number of Openings 1
Apply on the Company Site

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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