RN Quality Manager
UnitedHealth Group
- San Antonio, TX
- Permanent
- Full-time
- Manages Quality Coordinators, Clinical Quality Consultants (CQC) I, II and Senior CQC and/or support staff (Community Health Care Worker, Transition Care Navigators) is responsible for the overall success of the market's HEDIS/Star results for contracted physicians
- Responsible for all aspects of staff development to include hiring, training, coaching and development
- Maximizes staff performance and technical expertise through clearly defined objectives, training, skill development and leadership to ensure quality services to all customers
- Delegate, monitor and control work progress on key HEDIS/Star metrics, initiatives/action plans, staff productivity, and administrative expenses
- Participates in development and implementation of systems and processes that support quality operations
- Maintains effective cross functional services by working effectively with the Medical Director, Market Medical Director, Market Operations, Regional Team, Clinic Operations and other corporate departments
- Handles complex and/or difficult provider inquires and/or problems and facilitates resolution of provider issues. Continuously strive to ensure that favorable relationships are maintained while ensuring the interest of the organization
- Takes ownership of total work process and provides constructive information to ensure physician partners have support to meet initiatives
- Analyzes data while collaborating and/or participating in discussions with colleagues and business partners to identify potential root cause of issues
- Demonstrate understanding of providers' goals and strategies in order to facilitate the analysis and resolution of their issues
- Work with relevant internal stakeholders to identify obstacles and barriers identified by providers, and methods for removing them
- Communicate and advocate providers' needs to internal stakeholders in order to drive creation of solutions that meet our HEDIS/Star goals
- Communicate industry and company information to providers through various means (e.g., newsletters; emails; outreach calls; teleconference; conferences; on-site meetings)
- Develops and coaches staff to facilitate strategic business meetings with physician groups and their staff
- Guides, oversees and ensures competency of the Quality market staff
- Assist corporate and local education team and provides input on tools used to education quality staff and other local provider support staff
- Ensures all education objectives are being met, both on a formal and ad-hoc basis
- Responsible for ensuring the quality staff is responding to market operation and provider inquiries
- Facilitates provider discussions and assists in negotiating resolution to escalated provider issues with the capability to determine if/when issues require escalation
- Collectively works with cross functional leadership to eliminate duplication of efforts and member or provider abrasion
- Includes up to 50 - 75% local travel
- Performs all other related duties as assigned
- 4+ years of related experience in Quality/HEDIS/CMS Stars, and ICD10/CPT/CPT II coding knowledge, Provider Relations
- 1+ years of supervisory experience
- Solid working knowledge of Medicare quality operations including HEDIS, Stars, Coding and Medicare Advantage
- Knowledge of state and federal laws relating to Medicare
- Advanced Microsoft Office skills, proficient in Excel
- Exceptional analytical and data representation expertise
- Ability and willingness to travel, both locally and non-locally, as determined by business need
- Project Management experience
- Solid knowledge base of clinical standards of care, preventative health, and STAR measures
- Solid financial analytical background within Medicare Advantage plans (Risk Adjustment/STARS Calculation models)
- Ability to lift up to 10 pounds
- Ability to sit for extended periods of time
- Ability to stand for extended periods of time
- Ability to use fine motor skills to operate office equipment and/or machinery
- Ability to receive and comprehend instructions verbally and/or in writing
- Ability to use logical reasoning for simple and complex problem solving