For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)
The Manager of Clinical Process Quality assesses, plans, implements, and evaluates the quality of medical record chart reviews that are conducted to ensure there is consistency and accuracy across all reviewers. Provides direction, task delegation, and assistance to Quality Analysts in conducting the nursing process when performing quality monitoring of medical record chart reviews to ensure thorough analysis. Reports outcome of reviews for improvement in accuracy to appropriate managers and maintains consistency across all reviewers.
The Manager of Clinical Process Quality facilitates and leads DataRAP® process improvement efforts and ensures that the processes put in place maintain continuous compliance with state and federal requirements and that any new regulations are implemented in a timely manner. This position works collaboratively with senior leaders within DataRAP® as well as with other managers / departments impacted by the DataRAP® process to ensure that efforts are expended to continuously improve processes and create greater efficiencies and effectiveness of the entire DataRAP® process.
This position will also ensure that the processes for accepting attestations and other documentation from providers are performed in a timely and accurate manner to meet the objectives of all entities served, which include: DataRAP® staff, providers, medical group administrators, business associates, PHC and senior management.Primary Responsibilities:
This position is based out of the San Antonio office and will require some in market and out of market travel as needed.
- Provides day-to-day oversight of Quality Analysts and Medical Coding Coordinators for the DataRAP® department to ensure DataRAP® processing is completed timely and accurately
- Develops quality audit program to ensure quality of medical record reviews are performed accurately and consistently by each reviewer
- Works with the Chief Education Development Officer to ensure training for providers is consistent and accurate
- Develops, in partnership with DataRAP® leaders, policies and procedures, process metrics, data collection tools, and presentations of resultant data as it relates to risk, change control, and policy and procedure issues throughout the entire DataRAP® process
- Coordinates HEDIS activities as required by Physicians Health Choice as well as coordinates HEDIS reviews with Director of Clinical Data Operations
- Ensures continuous improvement in the development and implementation of DataRAP® medical record review processes and resource tools
- Manages the continued implementation of DataRAP® application and quality upgrades to DataRAP® applications
- Continually develops and implements quality improvement initiatives to maintain compliance with CMS and ICD-10 coding requirements
- Responsible for monthly reporting and tracking of medical record chart reviews and return audit process for all markets assigned
- Manages and assists with the development of the department budget by controlling expenses indicated within the budget plan, and provides justification for expenditures outside of budget plan
- Oversees and coordinates preparation activities for CMS and/or health plan audits. Performs mock CMS audit to ensure readiness in event of CMS audit. Prepares and serves as the department representative for the interview/audit process with CMS and/or health plan auditors
- Verifies, reviews, and communicates audit results and reports and institutes corrective action/follow-up
- Works with IS to provide nurse productivity reports and analysis to senior leaders. Informs and educates the DataRAP® team on return audit workflow and operations
- Selects and uses a wide variety of quality and auditing tools and techniques in practical applications to evaluate the effectiveness of the quality program
- Acquires and analyzes data using appropriate standard quantitative methods to facilitate process analysis and improvements
- Establishes performance improvement teams as necessary to address any issues identified
- Ensures adequate staffing is in place to meet market demands. Manages the staffing FTEs within budgeted guidelines. Provides employee coaching, counseling, and annual performance reviews
- 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.
- Education required:
- Bachelor's degree in Nursing, or
- Associate's degree in Nursing combined with four or more years of experience
- Current, unrestricted RN license required, specific to the state of employment
- 5+ years of RN-level clinical nursing experience
- 3+ years of management experience in a clinical setting
- CPC certification or ability to obtain one within nine months from the American Academy of Professional Coders
- Knowledge of ICD-10 coding
- Demonstrated leadership ability to manage and direct various levels of staff
- Ability to effectively manage projects, plan and implement programs and evaluate accomplishments
- Ability to effectively report data, facts and recommendations in oral and/or written form
- Ability to analyze facts and exercise sound judgment, arriving at proper conclusions
- Ability for adaptability and flexibility
- Analytical, problem solving, time management and attention to detail skills
- Goal directed, results oriented and change management attributes
- Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.
Physical & Mental Requirements:
- Bachelor of Science in Nursing (BSN) or other related Bachelor's degree
- Certification as an RN coder or actively pursuing certification
- Process/Quality improvement experience
Careers with WellMed.
- Ability to lift up to 25 pounds
- Ability to push or pull heavy objects using up to 50 pounds of force
- Ability to sit for extended periods of time
- Ability to stand for extended periods of time
- Ability to use fine motor skills to operate office equipment and/or machinery
- Ability to receive and comprehend instructions verbally and/or in writing
- Ability to use logical reasoning for simple and complex problem solving
Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 350,000 lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)**PLEASE NOTE**
The sign on bonus is only available to external candidates. Candidates who are currently working for a UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time, or per diem basis ("Internal Candidates") are not eligible to receive a sign on bonus.
Diversity creates a healthier atmosphere: OptumCare 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment
Job Keywords: Manager, RN, CPC, risk adjustment, coding, nurse manager, chart review, San Antonio, Texas, TX