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 Director of Contracted Clinical Support for DNG services is responsible for the supervision, evaluation and direction of the Optimal Care / Utilization and Quality Management process. The position will ensure compliance with the WellMed expectations for prospective, concurrent, retrospective and transition to out-patient care coordinating with physicians, hospitals and ancillary care and empowers team members through active problem solving and resource direction. The director is responsible for timely completion of documentation audits, and reviewing and mentoring team members to meet and exceed all documentation and compliance standards. The director manages Clinical Quality Consultants (DNG) to drive consistency, efficient processes and best practices with PCP/ providers designed to achieve a minimum of 4 STAR rating. This role will direct CQC team to develop and create quality CQI initiatives, recommend quality remediation plans and create tools and databases to capture relevant date for region. Primary Responsibilities:
- Directly manages Clinical Quality Consultants (DNG) to drive consistency, efficient processes and best practices with PCP/ providers designed to achieve a minimum of 4 STAR rating
- Directs CQC team to develop and create quality CQI initiatives, recommend quality remediation plans and create tools and databases to capture relevant date for region
- Solves problems and/or reviews facts, and selects the best solution from identifying alternatives with the ability to apply individual reasoning to the solution of a problem and identifies and reports processes or procedures that require modification
- Conducts annual evaluations of team members according to enterprise timeline and process; provides feedback in a constructive manner and respects the confidentiality of personnel issues
- Ensure regular attendance at PCC in assigned region, mentoring lower level case managers; reviews referrals prior to PCC, assists with complicated referral requests and assists with concerns and benefit application
- Ensures PTG's are regularly scheduled and supported in assigned region, mentoring staff (LVN and CTA's), reviews referrals prior to PTG to ensure difficult and complex patients are supported appropriately
- Oversee CQC market business plan to support and motivate Providers so they engage in STAR measures to achieve 4 star or higher
- Support CQC's to identify and assess provider/group barriers to achieving targeted outcomes and user friendly options to support practices success
- Be SME for all STAR and quality related activities in assigned market
- Provide analytical interpretation of STARs and HEDIS reporting for CQC team including executive summaries for provider groups
- Attends and contributes to strategic planning meetings at assigned team clinics as well as to departmental processing improvement meetings
- Takes ownership of the total work process and provides constructive information to minimize problems, increase customer satisfaction and improve job efficiency. Makes suggestions to appropriate supervisors as well as participates in the budgeting process by informing the manager of capital and operating needs
- Strives to personally expand working knowledge of all aspects of WellMed departments and develop team skills
- Attends educational offerings to keep abreast of changes and comply with licensing requirements
- Participates in UM/quality improvement committees and conducts special UM/QI studies as necessary
- Liaison to market providers for Optimal care and quality objectives
- Assures team fosters discharge plan collaboration with patient/family, attending physician and facility Case Manager
- Performs all duties to customers in a prompt, pleasant, professional and responsible manner regardless of the stressful nature of the situation
- Guides and answers patientquestions, contract issues, and updates physicians/medical groups of preferred contracts, providers, facilities and hospital utilization and noncompliance issues
- 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:
- Current unrestricted Registered Nurse (RN) license in the applicable state of employment
- 6+ years of experience in medical or hospital-based nursing or case management, discharge planning, utilization review or other cost containment role
- 3+ years of HEDIS/ STAR experience
- Solid knowledge of Medicare market, products and health care industry
Preferred Qualifications:
- Medicare criteria knowledge
- Sound knowledge of NCQA and federal regulations
- Proven solid relationship building skills with clinical and non-clinical staff
- Proven ability to solve process problems crossing multiple functional areas and business units
Physical & Mental Requirement:
- 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 employers 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.