Clinical Quality LPN - Las Cruses, NM

Las Cruces, New Mexico
Jun 28, 2022
Jun 30, 2022
Contract Type
Full Time
Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)

Positions in this family require a current, unrestricted nursing  license (i.e. RN, LPN, LVN) in the applicable state, as indicated in the function description and/or job title.

Positions in this function include RN roles (with current unrestricted licensure in applicable state) responsible for clinical quality audits and peer reviews.

Primary Responsibilities:

  • Has basic knowledge of theories, practices and procedures in a function or skill
  • Performs routine or structured work
  • Responds to routine or standard requests
  • Uses existing procedures and facts to solve routine problems or conduct routine analyses
  • Depends on others for instruction, guidance or direction
  • Basic, structured, standard approach to work

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:

  • Undergraduate degree or equivalent experience
  • 3+ years of healthcare experience to include experience in a managed care setting
  • 3+ years of experience with data analysis/quality chart reviews
Preferred Qualification:

  • Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
Functional Competency & Description
CQM_Review/Research Clinical Documentation

  • Review technical metrics/specifications/measures -Evaluate documentation of medical care
  • Review/interpret medical records/data to determine whether there is documentation that medical services were rendered -Determine/verify whether or not preventative services were rendered 
  • Identify members requiring additional follow-up (e.g., referral to Case Management)
  • Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC) 
  • Run/pull/prioritize relevant data/reports (e.g., member level data, geographical trends, provider data)
  • Prioritize providers for medical chart review (e.g., high volume members not seen)
  • Manipulate and leverage multiple databases/Electronic Medical Records applications(e.g., provider panels, medical review databases) to sort, search, and enter information
  • Identify incomplete/inconsistent information in medical records and label missing measures/metrics/concerns 
CQM_Analyze Clinical Documentation and Make Referrals

  • Review relevant HEDIS specifications to guide chart review 
  • Review/interpret/summarize medical records/data to address quality of care questions Generate reports/findings of reviews
  • Review provider responses to reports/findings and correlate with medical records
  • Review/verify medical claims coding 
  • Review medical records for compliance with regulatory guidelines (e.g., NCQA, state Medicaid contracts, Clinical Practice 
  • Guidelines)
  • Verify necessary documentation is included in medical records  
  • Maintain HIPAA requirements for sharing minimum necessary information
  • Based on review of clinical data/documentation, identify potential quality of care issues (e.g., variations from standard practice potentially resulting in adverse outcomes) and potential fraud/waste/abuse.
  • Refer issues identified to relevant parties (e.g., review committee, Case Management, Medical Directors) for further review/action 
  • Apply knowledge of relevant peer review protection, reporting requirements, and confidentiality policies, procedures and regulations 
CQM_Develop/Implement Action Plans/Follow Up

  • Talk to provider offices to address corrective action plans
  • Talk to provider offices about member service needs or care rendered
  • Educate provider representatives/office staff to address/improve processes/reduce recurring problems
  • Provide technical guidance to providers to improve/standardize quality of care
  • Assist provider/office staff in developing strategies for increasing member adherence with preventative or other support services
  • Refer inconsistencies/problems with medical claims coding to appropriate parties for resolution (e.g., claims department) Educate providers on proper medical record documentation for regulatory compliance
  • Educate others on technical metrics/specifications/measures
  • Explain/convey technical specifications regarding action plans/follow up and adjust communication to level of audience Explain how provider scores are calculated/determined
  • Direct activities/target outreach to increase quality scores (e.g., STAR ratings)
  • Initiate action when preventative services are not rendered as planned 
CQM_Demonstrate Business/Industry Knowledge

  • Demonstrate knowledge of healthcare insurance industry products (e.g., HMO, PPO, ASO)
  • Demonstrate knowledge of Medicare and Medicaid benefit products including applicable state regulations 
  • Demonstrate knowledge of applicable area of specialization (e.g., rehab, pediatric, home care, home and community based services)
  • Acquire proficiency in utilizing multiple medical record systems to obtain relevant data
  • Leverage relevant search engines and data capture software (e.g., HEDIS, HCC) 
  • Demonstrate knowledge of computer functionality, navigation, and software applications (e.g., Windows, Microsoft Office applications, phone applications, fax server)
  • Demonstrate knowledge of specific software applications associated with the job function (e.g., navigation of relevant computer applications or systems, intranet databases, records management or claims databases) Provide input into development of systems/databases to capture metrics/measures 
CQM_Drive Effective Clinical Decisions within a Business Environment

  • Asks critical questions to ensure member/customer centric approach to work
  • Identifies and considers appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed 
  • Utilizes evidencebased guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
  • Identifies and implements innovative approaches to the practice, in order to achieve or enhance quality outcomes and financial performance
  • Uses appropriate business metrics (e.g. member/FTE, length of stay, readmission rates, STAR ratings, member engagement rates) and applicable processes/tools (e.g. cost benefit analysis, return on investment, proforma, staffing calculator) to optimize decisions and clinical outcomes 
  • Prioritizes work based on business algorithms and established work processes, or in their absence, identifies business priorities and builds consensus to triage and deliver work (e.g. assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up.)  
  • Understands and operates effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state.) 
Values Based Competencies
Integrity Value: Act Ethically

  • Comply with Applicable Laws, Regulations and Policies
  • Demonstrate Integrity
Compassion Value: Focus on Customers

  • Identify and Exceed Customer Expectations
  • Improve the Customer Experience
Relationships Value: Act as a Team Player

  • Collaborate with Others
  • Demonstrate Diversity Awareness
  • Learn and Develop
Relationships Value: Communicate Effectively

  • Influence Others
  • Listen Actively
Innovation Value: Support Change and Innovation

  • Contribute Innovative Ideas
  • Work Effectively in a Changing Environment
Performance Value: Make FactBased Decisions

  • Apply Business Knowledge
  • Use Sound Judgement
Performance Value: Deliver Quality Results

  • Drive for Results
  • Manage Time Effectively
  • Produce HighQuality Work

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ 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)

WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

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.

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