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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 Manager of Clinical Process Quality assesses, plans, implements, and evaluates the quality of medical record chart reviews that are conducted to ensure there is consistency and accuracy across all reviewers. Provides direction, task delegation, and assistance to Quality Analysts in conducting the nursing process when performing quality monitoring of medical record chart reviews to ensure thorough analysis. Reports outcome of reviews for improvement in accuracy to appropriate managers and maintains consistency across all reviewers.

The Manager of Clinical Process Quality facilitates and leads DataRAP® process improvement efforts and ensures that the processes put in place maintain continuous compliance with state and federal requirements and that any new regulations are implemented in a timely manner. This position works collaboratively with senior leaders within DataRAP® as well as with other managers / departments impacted by the DataRAP® process to ensure that efforts are expended to continuously improve processes and create greater efficiencies and effectiveness of the entire DataRAP® process.

This position will also ensure that the processes for accepting attestations and other documentation from providers are performed in a timely and accurate manner to meet the objectives of all entities served, which include: DataRAP® staff, providers, medical group administrators, business associates, PHC and senior management.

Primary Responsibilities:

• Provides day-to-day oversight of Quality Analysts and Medical Coding Coordinators for the DataRAP® department to ensure DataRAP® processing is completed timely and accurately
• Develops quality audit program to ensure quality of medical record reviews are performed accurately and consistently by each reviewer
• Works with the Chief Education Development Officer to ensure training for providers is consistent and accurate
• Develops, in partnership with DataRAP® leaders, policies and procedures, process metrics, data collection tools, and presentations of resultant data as it relates to risk, change control, and policy and procedure issues throughout the entire DataRAP® process
• Coordinates HEDIS activities as required by Physicians Health Choice as well as coordinates HEDIS reviews with Director of Clinical Data Operations
• Ensures continuous improvement in the development and implementation of DataRAP® medical record review processes and resource tools
• Manages the continued implementation of DataRAP® application and quality upgrades to DataRAP® applications
• Continually develops and implements quality improvement initiatives to maintain compliance with CMS and ICD-9 coding requirements
• Responsible for monthly reporting and tracking of medical record chart reviews and return audit process for all markets assigned
• Manages and assists with the development of the department budget by controlling expenses indicated within the budget plan, and provides justification for expenditures outside of budget plan
• Oversees and coordinates preparation activities for CMS and/or health plan audits. Performs mock CMS audit to ensure readiness in event of CMS audit. Prepares and serves as the department representative for the interview/audit process with CMS and/or health plan auditors
• Verifies, reviews, and communicates audit results and reports and institutes corrective action/follow-up
• Works with IS to provide nurse productivity reports and analysis to senior leaders. Informs and educates the DataRAP® team on return audit workflow and operations
• Selects and uses a wide variety of quality and auditing tools and techniques in practical applications to evaluate the effectiveness of the quality program
• Acquires and analyzes data using appropriate standard quantitative methods to facilitate process analysis and improvements
• Establishes performance improvement teams as necessary to address any issues identified
• Ensures adequate staffing is in place to meet market demands. Manages the staffing FTEs within budgeted guidelines. Provides employee coaching, counseling, and annual performance reviews
• Performs all other related 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:

• Bachelor’s degree in Nursing, or Associate’s degree in Nursing combined with four or more years of experience
• Current, unrestricted RN license required, specific to the state of employment
• CPC certification or ability to obtain one within nine months from the American Academy of Professional Coders
• 5+ years of RN-level clinical nursing experience
• 3+ years of management-level experience in a clinical setting
• Solid knowledge of ICD-9 coding
• Demonstrated leadership ability to manage and direct various levels of staff
• Demonstrated ability to effectively manage projects, plan and implement programs and evaluate accomplishments
• Demonstrated ability to effectively report data, facts and recommendations in oral and/or written form
• Demonstrated ability to analyze facts and exercise sound judgment, arriving at proper conclusions
• Demonstrated ability for adaptability and flexibility
• Demonstrated solid analytical, problem solving, time management and attention to detail skills
• Demonstrated to be goal directed, results oriented and change management attributes

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN) or other related Bachelor’s degree
• Certification as an RN coder or actively pursuing certification
• Process/Quality improvement experience

Physical & Mental Requirements

• Ability to properly drive and operate a company vehicle

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.

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.