Sr Quality HEDIS RN

    • San Antonio, TX

Position Description

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)

The Senior Clinical Quality Consultant (CQC) will drive consistency, efficient processes and share best practices, in a collaborative effort with the provider and large or complex groups, designed to facilitate a minimum 4 STAR quality performance. The Sr CQC will participate in quality improvement initiatives, attend monthly or joint operating committee meetings, develop recommendations for quality remediation plans and create tools and databases to capture relevant data for each region. This position will work collaboratively with each regional/market team and their leadership in a matrix relationship. This position may serve as the team lead for the clinical quality consultants in the assigned market and has responsibility for the network's quality performance.

Please note: This is an office based (call center) position located at our office at 6000 NW Pkwy San Antonio, TX

Primary Responsibilities:

  • Develop market business plans to motivate providers and large or complex group leadership to engage in improving Stars measures to be 4 STARS or higher
  • Place outbound calls to members to ascertain information from the patient regarding HEDIS and Quality measures related to their care as well as obtain member information regarding any possible gaps in care
  • Provide analytical interpretation of Stars and HEDIS reporting, including executive summaries to plan and provider groups
  • Be the primary subject matter expert for all STARS related activities within their assigned market(s) working within a matrix relationship which includes Quality corporate operations and Regional/Market operations
  • Lead or participate and present in weekly, Monthly, Bi-monthly, Quarterly and/or Annual business Review meetings related to STAR activities which summarize provider and large group performance and market performance as requested by or required by Quality or Regional leadership
  • Analyze and evaluate provider and large group structure and characteristics, provider group/provider office operations and personnel to identify the most effective approaches and strategies
  • Assist in developing of training and analytical materials for Stars and HEDIS
  • Identify and assess decision makers and other key provider group personnel with a focus on identifying barriers to achieving targeted outcomes, focus communications and efforts accordingly
  • Develop solution-based, user friendly initiatives to support practice success

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 and unrestricted RN in the state of Texas
  • 4+ years of healthcare experience, including experience in a managed care setting
  • 2+ years of experience in provider facing interactions, including provider education

  • 2+ years of experience with data analysis and/or quality chart reviews. Must be able to review data and provide recommendations for improvement
  • Strong knowledge of the Medicare market, products and competitors
  • Experience in managed care working with network and provider relations
  • Experienced using Microsoft office applications, including databases, word - processing, and excel spreadsheets
Preferred Qualifications:
  • 2+ years of experience in HEDIS / Star programs, preferably in a clinical quality consultant role
  • Billing and CPT coding experience
  • Call Center Experience
  • Clinical data abstraction experience
  • Good business acumen, especially as it relates to Medicare
  • Undergraduate degree preferred, post graduate degree highly


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 240,000+ 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)

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: RN, Clinical Quality, CQC, Call Center, HEDIS, STARs, manage care, Medicare, patient outreach, San Antonio, Texas, TX

With offices around the world, UnitedHealth Group's headquarters are located in the Minneapolis metropolitan area.

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