RN Senior Clinical Quality Consultant Compact Lics CST

About the position WellMed, part of the Optum family of businesses, is seeking a Registered Nurse to join our team. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone. At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together. The WellMed Quality Clinical Programs team supports WellMed Medical Management by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close STARs measure gaps in care, e.g. medication adherence, care for older adults, medication reconciliation post discharge, A1c, etc. Our interdisciplinary service delivery team is comprised of Registered Nurses, Licensed Vocational Nurses, and Social Workers. The Registered Nurse will report into the Manager of Clinical Programs. The Registered Nurse will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. In addition, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work a flexible schedule to support the hours of operation of the business.

Responsibilities

• Strictly adheres to department's metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests
• Primarily to make outbound calls but occasionally help manage the inbound call queue from patients, patient representatives, providers and other medical staff, while strictly adhering to established protocols and scripting
• Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services
• Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments
• Educate patients on health conditions and necessity of route screening but assisting with appointment scheduling (A1c, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.)
• Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided
• Review available medical records for core measures to submit for closure of HEDIS/STARS measures
• Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs, (Pharmacy assistance programs, meals on wheels, LIS)
• Document thoroughly all calls and actions taken within core systems

Requirements

• Active, unrestricted Registered Nurse license
• Have Compact License and willing to support CST
• 4+ years of RN experience, including experience in a managed care setting
• 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role
• 2+ years of call center experience
• 2+ years of experience with data analysis and/or quality chart reviews. Must be able to review paper and electronic medical records and charts
• Proven solid knowledge of the Medicare HEDIS/Stars measures
• Experienced using Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets. Must be proficient in Excel
• Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
• Demonstrated ability to manage multiple complex, concurrent projects
• Proven excellent written and verbal communication and relationship building skills
• Demonstrated solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
• Proven excellent customer service skills and communication skills

Nice-to-haves

• Undergraduate degree or post graduate degree
• Billing and CPT coding experience
• Clinical data abstraction experience
• Proven adaptable to change
• Proven good business acumen, especially as it relates to Medicare

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

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