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)
This is a Work At Home position which will report to the Director, Medical Management Clinical Operations or the Vice President, Medical Management Clinical Operations
- Monitors monthly and quarterly UM performance and quarterly quality performance of assigned delegates
- Analyzes data and interprets results to assess the performance of the delegate
- Contributes to Quality Team strategies to improve HEDIS, STARs, and other quality metrics
- Identifies internal and delegate strategies for improvement including the identification of specific outcomes and metrics to monitor progress to a goal
- Provides feedback and makes recommendations about process improvement, in coordination with the Market Medical Director, to clinical delegates; presents to delegate workgroups, delegates, and leadership
- Provides consulting to clinical delegates on a variety of topics including utilization management, case management, disease management programs, and operational processes, including sharing best practices
- Participates in delegate transition activities for delegates that are new or terminating, including providing consultation on clinical processes
- Acts as an internal subject matter expert to UHC to consult on the development, implementation and maintenance of new and revised medical management systems and business processes
- Acts as the liaison for clinical issues related to delegation
- Has knowledge of delegation agreements, local market data, and other data utilized to develop strategies for process improvement
- As necessary, collaborates with UHC clinical teams to act as a subject matter expert in the development of delegate process improvement initiatives including determining the root cause of issues, proposing solutions, and overseeing recommended changes
- Presents findings at Joint Operating Committee (JOC) meetings and in Medical Management meetings to the delegate’s Medical Directorship and other clinical leaders
- Attends and contributes in regular internal meetings with Clinical, Quality, Health Plan, Network Management, Sales and other staff, as appropriate
- Establishes and maintains strong working relationships with key internal and external constituencies
- Travel is frequent, up to 50% of the month with travel to local, regional and national Medical Groups / IPAs
- Systemically, support delegate activities designed to improve clinical outcomes in an efficient and effective manner
- Consult in the development of targeted programs and strategies designed to achieve appropriate utilization goals across the care continuum while maintaining high levels of healthcare quality;
- Consult with the delegate and UHC partners to implement strategies to improve population health
- Collaborate with UHC partners to implement improvement strategies to simplify and streamline processes
- Consult with the delegate regarding systemic process improvement activities in the management of catastrophic, disease and population health management and escalate to UHG partners for resolution (e.g. UHN, Optum, NICM)
- Current Registered Nurse license as required by applicable state licensure board
6+ years of relevant work experience in the Medical Group / IPA or Health Plan setting for concurrent review, prior authorizations, case management, referral management, retrospective review and discharge planning in hospital, ambulatory and ancillary settings
- Strong clinical program development and program management skills, including
- Proven ability to identify operational process gaps and clinical gaps in care
- Demonstrated knowledge of root cause analysis and solution development
- The ability to gain acceptance from others of a need, plan or idea to achieve a mutually beneficial outcome
- Advanced proficiency with Microsoft Excel, Word, and Access
- Proficiency in ICD-CM, CPT, DRG and HCPCS coding
- Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others
- Demonstrated ability to present to and / or train large groups.
- Advanced proficiency in industry knowledge
- Access to reliable transportation that will enable you to travel to client and / or patient sites within a designated area
- This position requires a local market presence and involves up to 50% travel. Ideal candidate must be available for face to face meetings with clients in the Northern CA markets several times a week.
- Master’s degree and or managed care experience at the management level
Acute inpatient experience
- Clinical operations experience in the Medical Group / IPA / Hospital and health plan settings
- Demonstrated effectiveness in performing statistical analysis and presentation of utilization management data, including one-on-one meetings with medical directors/physician leaders
Careers with UnitedHealthcare
Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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.