Job Description

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start  Caring. Connecting. Growing together. 

The Clinical Practice Consultant (CPC) will be responsible for strategically developing clinically oriented provider and community-based partnerships, education, and action plans to increase quality scores based on HEDIS, NCQA, and state specific quality measures. This role will be responsible for ongoing management of provider practice quality measures. Through HEDIS documentation collection and review, monitoring, measuring, and reporting on key metrics, the Clinical Practice Consultant assists providers in meeting quality standards, state contractual requirements and pay for performance initiatives.

If you reside in Idaho, you will have the flexibility to work remotely* as you take on some tough challenges. 

Primary Responsibilities:

• Ongoing management of provider practice and community education on HEDIS, NCQA, and state specific quality measures
• Work with provider practices to develop action plans to drive quality improvement
• Educate 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
• Analysis, review, and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements, and pay for performance initiatives
• Serve as subject matter expert (SME) for assigned Medicaid/Medicare HEDIS / CMS measures, preventive health topics; lead efforts with clinical team to research and design educational materials for use in practitioner offices; serve as liaison with key vendors supporting Medicaid/Medicare HEDIS / CMS Measures; consult with vendors to design and implement initiatives to innovate and then improve Medicaid/Medicare HEDIS / CMS Measure rates
• Identify patient care opportunities and collaborate with physician practices to ensure appropriate member appointments and care
• Coordinate and perform 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
• Investigate 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
• Document and refer 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
• Other 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:

• 3+ years of Clinical experience in a physician practice, outpatient facility or a FQHC
• 2+ years of quality improvement experience
• 2+ years of Medicare / Medicaid experience
• Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint
• Reliable transportation to travel to physician offices locally up to 75% of the time
• Resident of Idaho 

Preferred Qualifications:

• Current, unrestricted RN license in the State of ID
• 2+ years of HEDIS experience
• Health insurance industry experience, including regulatory and compliance
• Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, governing and regulatory agency requirements and the managed care industr

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

The salary range for this role is $71,600 to $140,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. 

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