About the position
Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.
The Clinical Quality RN will drive consistency, efficient processes and share best practices in a collaborative effort with the Quality team and leadership in order to facilitate a minimum 4 STAR rating. The Clinical Quality RN will participate in quality improvement initiatives including Chart Chase and Supplemental Data Source (SDS) and Primary Source Verification (PSV) as well as Quality Assurance and Overreading work. This position will work collaboratively with other staff members, managers and leadership and the market in a matrix relationship.
If you have a Compact Lics, you will have the flexibility to work remotely as you take on some tough challenges.
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.
Responsibilities
• Complete SDS, PSV, Over-read throughout the year achieving and maintaining high productivity goals in order to improve Stars measures to be 4 STARS or higher
• Achieve and maintain a high level of accuracy rates of 98%25 or above
• Serve as a Subject matter expert on HEDIS Measures, DataRAP and Chart Chase Tool (CCT)
• Be the primary go to person for all STARS related activities within their assigned market(s) working within a matrix relationship which includes Quality corporate operations and Regional/Market operations
• Assist in developing of training and materials to help team achieve best practices in Stars and HEDIS
• Performance as requested by or required by Quality
• Identify and assess decision makers and other key provider group personnel with a focus on identifying barriers to achieving targeted outcomes
• Focus communications and efforts accordingly
• Develop solution-based, user friendly initiatives to support practice success
Requirements
• Bachelor of Science in Nursing, Healthcare Administration or a related field required. (Eight additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor's degree)
• Registered Nurse with current license in Texas, or other participating States
• 5+ years of progressively responsible healthcare experience to include experience in a managed care setting, and/or hospital settings, and/or physician practice setting
• 3+ years of experience in managed care with at least two years of Utilization Management experience
• Knowledge and experience with CMS, and/or NCQA
• Proficiency with Microsoft Office applications
• Willing to occasionally travel in and/or out-of-town
Nice-to-haves
• Health Plan or MSO quality, audit or compliance experience
• Solid Knowledge of Medicare and HEDIS standards
• Auditing, training or leadership experience
Benefits
• a comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution