UnitedHealth Group RN Clinical Quality Consultant - Waltham, MA in Boston, Massachusetts

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)

Reporting to the Senior Director of Quality in the Massachusetts Community Plan, the RN Clinical Quality Consultant utilizes a broad knowledge of health plan quality improvement and health care to plan, direct and manage all assigned areas of the Department. Responsible for development, deployment, and ongoing monitoring of programs and interventions aimed at continuous improvement, including clinical best practices and clinical practice guideline research. Responsible for processes related to clinical data collection, analysis, and reporting. Responsible for assuring all processes are compliant with applicable regulations and all appropriate documentation is maintained.

If you are located in Waltham, Boston, MA , you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Develop understanding of customer requirements and/or expectations and anticipate needs to determine appropriate course of action

  • Develop audit or review processes (e.g., automated/technically driven)

  • Review relevant agreements (e.g., contractual, intersegment) and obtain clarification as necessary

  • Read and interpret standards/requirements and/or technical specifications (e.g., structure and process, CMS star ratings, URAC, NCQA/HEDIS/ CAHPS/member satisfaction specifications, SNP)

  • Evaluate current processes, compare to relevant standards or specifications and identify gaps in compliance or performance

  • Perform/participate in assessments of the audit or review (e.g., interpreter reliability of audit findings across auditors)

  • Work cross-functionally, making recommendations or clarifying information to assist in closing gaps that are identified or meeting customer expectations

  • Work with auditors or key stakeholders for review/approval of results

  • Develop and/or assist with corrective action plans based on audit findings or customer feedback

  • Review processes and performance against customer expectations to provide needed information or service

Required Qualifications:

  • BS or BA degree

  • Current and unrestricted RN license in Massachusetts

  • 5+ years of experience with projects managing quality initiatives and quality programs

  • Experience with leading Performance Improvement or Quality Improvement Projects

  • Experience with Data Analysis and PDSA cycles

  • Knowledge of NCQA, HEDIS, STARS, and CMS guidelines

  • Must live within a commutable distance of the Boston/Waltham, MA office location

Preferred Qualifications:

  • Master’s degree

  • Experience with Medicaid, Medicare, and Senior Care Options and One Care programs highly desirable

  • Excellent written and oral communication skills

Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work. SM

*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.

Job Keywords: RN, Clinical Quality, HEDIS, STARS, NCQA, CMS, Quality Improvement, Boston, Waltham, Massachusetts, MA, Telecommute, Telecommuting, Telecommuter