RN, HEDIS Quality Manager - North and Central Texas - Hybrid

Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Explore rewarding opportunities for physicians, clinical staff and non-patient-facing roles. Join us and discover the meaning behind Caring. Connecting. Growing together.   

The Quality Manager is responsible for driving consistency in program implementation designed to facilitate a minimum of a 4 Star quality rating.  These initiatives should result in contracted network being able to understand and support the vision to change the face of healthcare delivery for seniors. This will drive the financial viability of the market HEDIS/Star program and provide a full quality of care for the members. The responsibilities of this position demand a wide range of capabilities including: strategic planning and analysis skills; solid understanding of HEDIS and coding; management breadth to direct and motivate; highly developed communication skills;  and the ability to develop clear action plans and drive process, given often ambiguous issues with numerous interdependencies. This position will facilitate any unresolved issues that remain as a result from following the standard process.

Primary Responsibilities: 

• Manages Quality Coordinators, Clinical Quality Consultants (CQC) I, II and Senior CQC and is responsible for the overall success of the market's HEDIS/Star results for contracted physicians
• Responsible  for  all  aspects  of  staff  development  to  include  hiring,  training,  coaching  and development
• Maximizes staff performance and technical expertise through clearly defined objectives, training, skill development and leadership to ensure quality services to all customers
• Delegate, monitor and control work progress on key HEDIS/Star metrics, initiatives/action plans, staff productivity, and administrative expenses
• Participates in development and implementation of systems and processes that support quality operations
• Maintains effective cross functional services by working effectively with the Medical Director, Market Medical Director, Market Operations, Regional Team, Clinic Operations and other corporate departments
• Handles complex and/or difficult provider inquires and/or problems and facilitates resolution of provider issues. Continuously strive to ensure that favorable relationships are maintained while ensuring the interest of the organization
• Takes ownership of total work process and provides constructive information to ensure physician partners have support to meet initiatives
• Analyzes data while collaborating and/or participating in discussions with colleagues and business partners to identify potential root cause of issues
• Demonstrate understanding of providers' goals and strategies in order to facilitate the analysis and resolution of their issues
• Work with relevant internal stakeholders to identify obstacles and barriers identified by providers, and methods for removing them
• Communicate and advocate providers' needs to internal stakeholders in order to drive creation of solutions that meet our HEDIS/Star goals\
• Communicate industry and company information to providers through various means (e.g., newsletters; emails; outreach calls; teleconference; conferences; on-site meetings)
• Develops and coaches staff to facilitate strategic business meetings with physician groups and their staff
• Guides, oversees and ensures competency of the Quality market staff
• Assist corporate and local education team and provides input on tools used to education quality staff and other local provider support staff
• Ensures all education objectives are being met, both on a formal and ad-hoc basis.
• Responsible for ensuring the quality staff is responding to market operation and provider inquiries
• Facilitates provider discussions and assists in negotiating resolution to escalated provider issues with the capability to determine if/when issues require escalation.

• Collectively works with cross functional leadership to eliminate duplication of efforts and member or provider abrasion

• 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: 

• Registered Nurse with an active and unrestricted license to practice in the state of employment
• 5+ years of related experience in Quality/HEDIS/CMS Stars, and ICD10/CPT/CPT II coding knowledge, Provider Relations 
• 2+ years of supervisory experience
• Demonstrated working knowledge of Medicare quality operations including HEDIS, Stars, Coding and Medicare Advantage
• Demonstrated knowledge of state and federal laws relating to Medicare 
• Ability and willingness to travel, both locally and non-locally, as determined by business need
• Demonstrated exceptional analytical and data representation expertise
• Demonstrated advanced Microsoft Office skills. Must be proficient in Excel
• Valid driver's license, reliable transportation, and current automobile insurance, with the ability to travel up to 25% based on business needs

Preferred Qualifications: 

• Demonstrated solid knowledge base of clinical standards of care, preventative health and STAR measures
• Project Management experience
• Solid financial analytical background within Medicare Advantage plans (Risk Adjustment/STARS Calculation models)

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

  At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.