Tribal Quality Improvement Lead – Remote in NM

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. 

As the Tribal Quality Improvement (QI), you will be responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures.

If you are located in NM, you will have the flexibility to work remotely* as you take on some tough challenges. 

Primary Responsibilities:

• Responsible for ongoing management of tribal, Indian Health/638 provider practice and community education on state specific quality measures
• Works with tribal, Indian Health/638 provider practices to develop action plans to drive quality improvement
• Educates tribal, Indian Health/638 providers and office staff on proper clinical documentation, coding, and billing practices, CMS mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
• Analysis, review, and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements, and pay for performance initiatives
• Serves as subject matter expert (SME) for Tribal preventative health topics; leads efforts with clinical and four winds team to research and design educational materials for practitioner offices. 
• Serves as liaison with key vendors supporting Medicaid/Medicare HEDIS / CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve Medicaid/Medicare HEDIS / CMS Measure rates within the tribal communities
• Identifies patient care opportunities and collaborates with tribal physician practices to ensure appropriate member appointments and care
• Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
• Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion
• Documents and refers tribal providers’ non-clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
• Responsible for development, program updates, execution, and evaluation of ongoing tribal programs as related to identified Medicaid/Medicare/HEDIS/ CMS measures. 
• Responsible for development of monthly provider visit documentation, maintenance and reporting to Leadership  

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:

• 5+ years clinical, healthcare or insurance industry experience
• 3+ years of healthcare quality improvement
• Experience creating presentations and working with data to formally present information to physicians, administrators, state regulator, other providers and community partners
• Experience collaborating with and presenting to senior level leadership
• Proficient experience working with MS Word (create, edit and save documents) and Excel (create, edit and save spreadsheets, formulas)
• Knowledge of public health, in both rural and urban settings including those areas identified as tribal health arena
• Knowledge of social determinants of health in rural and urban setting in the Southwest including understanding of tribal lands
• Intermediate software applications skills that include, Microsoft Word, Excel, PowerPoint
• Ability to review data and make clinical interventions and consult others
• Ability to travel locally up to 25% of the time
• Currently reside in New Mexico
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy

Preferred Qualifications:

• Current unrestricted Registered Nurse (RN) licensure in the state of NM or Licensed Clinical Social Worker (LCSW) or 5 years relevant experience including 3 years of clinical experience related to primary responsibilities 
• CPHQ certification
• 5+ years clinical or healthcare experience, preference in Tribal Healthcare
• Experience creating and executing a strategic plan with measurable outcomes
• Experience working in Medicaid and/or Medicare
• Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, Population health approach and the managed care industry
• Background in Managed Care

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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.