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UnitedHealth Group Associate Quality Director - South Texas - WellMed in Edinburg, Texas

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 Associate Quality Director - South Texas 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 patient questions, 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:

  • BSN (Bachelors of Science in Nursing) or Associate’s Degree in Nursing AND/OR Foreign Medical Graduate Degree

  • 3+ years 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

  • 1+ years of CMS Quality Measures, and HCC RAF Coding experience

  • Strong knowledge of Medicare market, products and health care industry

  • This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor’s diagnosis of disease.

Preferred Qualifications:

  • Medicare criteria knowledge

  • Sound knowledge of NCQA and federal regulations

  • Strong relationship building skills with clinical and non-clinical staff

  • Ability to solve process problems crossing multiple functional areas and business units

Physical & Mental Requirements:

  • Ability to lift, push or pull > 35 lbs with assistance

  • 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

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors., WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for 550,000+ older adults with over 16,000 doctors’ offices 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: Manager, leadership, Provider engagement, Performance Manager, Quality Advocate, Quality, Project Management, Consulting, Providers, Member Groups, Contracts, Quality Improvement, McAllen TX, Arlingen TX, Reynosa TX, Brownsville, TX, WellMed, Healthcare, Bilingual, Registered Nurse, RN, Clinical Educator, Quality Training Lead , HEDIS/STAR, Consultant, San Antonio, New Braunfels, Seguin, Gonzales, Shiner, Yoakum, Boerne, Floresville, Helotes, 78249, Texas, TX