Clinical Practice Performance Consultant - Hawaii, Maui, Kauai Counties, HI - Lihue Hawaii

Company: UnitedHealthcare
Location: Lihue, Hawaii
Posted On: 05/04/2025

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.

If you are located on or near Kauai, Maui, or Hawaii Counties, you will have the flexibility to work remotely* as you take on some tough challenges. Please note that this is a work from home opportunity, but you still need to live in or near the posted area to travel up to 75% of the time covering Kauai, Maui and Hawaii Counties

Primary Responsibilities:

Educates providers and office staff on proper clinical documentation, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS/State Specific quality measures for provider and staff education during field visits -
Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating, and facilitating on a local level)
Serves as subject matter expert (SME) for assigned HEDIS/State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State Measure rates
Participates, coordinates, and/or represents the Health Plan at community-based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care
Reports provider issue trends of concerns to the Health Plan Quality Director and work with other departments to resolve as needed
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
Identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy -
Documents and refers 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 ensuring follow through
Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications
Preparing and presenting quality data and initiative at Quality Committee meetings


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:


4+ years of experience in managed care or equivalent healthcare experience, including regular interaction with providers regarding clinical quality improvement processes
Experience in designing and implementing quality improvement initiatives
Experience in data interpretation and using data to inform decision-making
Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and PowerPoint
Access to reliable transportation, and proof of automobile insurance -
Ability to Travel to physician offices locally up to 75% of the time, including off island travel


Preferred Qualifications:


Current unrestricted RN or MSW licensure in the State of Hawaii
Experience working in Medicaid and/or Medicare
Experience in managed care
Experience working with behavioral health patients, members, or providers
Account Management experience
Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements
Multilingual
Proven presentation skills with experience and comfortability presenting to others


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

The salary range for this role is $71,600 to $140,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.

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.


UnitedHealth Group is 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 is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. More...

    

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