Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The Clinical Quality Analyst - SME within the Risk Quality and Provider Enablement division of Optum Insight, provides technical expertise to abstraction and overread teams for IOA, HEDIS® Supplemental and Chart Chase. They will be responsible for quality spot audits, individual quality coaching, participating in office hours, abstraction support, tracking and reporting quality trends.
Demonstrated HEDIS® subject matter expertise for retrospective, prospective and administrative measures is essential to job performance. In addition, SME will provide essential support with audit queue.
This position is part time 20 hours/week during peak season (January - April). Employees are required to work nights and/or weekends during peak season as needed. It may be necessary, given the business need, to work occasional overtime/weekend.
We offer 1 week of on-the-job training. Employee should complete full training needs during the 1st week of class.
You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Participate in Medical Record spot audits
- Serve as a Subject Matter Expert of NCQA's HEDIS® Technical Specifications for all HEDIS® Retrospective, Prospective and Administrative Measures
- Provide leadership and participation on abstraction/overread office hours
- Review and respond to abstraction and overread questions and rebuttals (i.e., Coach Tracker)
- Responsible for reviewing all overread fails in the OQGA tool
- Responsible (as needed or as assigned) to assist with resolving abstraction logic errors
- Responsible to learn, understand and apply HEDIS®/CMS measure knowledge to support functional operation proficiency at a market or reporting population level
- Ability to work in a self-directive manner and apply critical thinking/problem solving skills by referencing available Technical Specifications, Business Process Documentation, Job Aids and other tools for clarity/guidance as needed
- Ability to meet team and departmental productivity expectations while maintaining quality standards
- Observe and comply with policies and procedures for assigned scope
- Quality Assurance
- Vendor Inter-Rater Reliability (VIRR)
- Medical Record Review Validation (MRRV)
- Inter-Rater Reliability (IRR)
- Abstraction (medical chart interpretation and data entry)
- When quality issues are identified, perform 1:1 coaching with abstractor/overreader when requested
- Provide feedback related to annual system updates for MRR abstraction tool as result of specification changes and/or process enhancements
- Participate in developing/pulling reporting documents for progress and results of abstraction
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:
- High School Diploma / GED
- Must be 18 years of age OR older
- 2+ years of healthcare experience
- 2+ years of experience reviewing medical records
- 2+ years of HEDIS® work experience, performing a wide range of functions with strong focus on medical record review and clinical oversight
- Ability to complete full training needs during the first week of class
- Ability to work nights and/or weekends during peak seasons as needed
- Ability to use Microsoft applications such as Outlook on a daily basis
- Ability to work up to 20 hours per week during peak season (January – April)
Preferred Qualifications:
- 2+ years of experience in a health care delivery organization
- Knowledgeable of current trends in HEDIS® in managed health care.
- Knowledgeable of NCQA, Stars, HEDIS®, HOS and CAHPS requirements.
- Familiarity with ICD-9-CM, CPT, DRG, LOINC, HCPCS, TOB, POS, NDC coding.
- Coding certificate from AAPC or AHIMA OR Clinical Certification such as LPN, RN, or CNA (Certified Nursing Assistant)
- Proficiency in presentation skills to audiences of various sizes
- Knowledge of Medicaid and/or Medicare programs
Telecommuting Requirements:
- Ability to keep all company sensitive documents secure (if applicable)
- Required to have a dedicated work area established that is separated from other living areas and provides information privacy
- Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C., Maryland Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. 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.Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 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.#RPO #RED #RPOLinkedIn