Job: Clinical Practice Consultant

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Jobing Description

***Qualified candidate must be able to travel throughout the state of Mississippi. Travel 90 - 100% of the time. Overnight travel required one to three nights per week.***

This position is responsible for ongoing HEDIS collection and improvement activities at the health plan and reports to the Quality Management Leader.

Coordinates and performs onsite medical record reviews at provider offices to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards, and where assigned investigation of quality of care and member complaints relative to quality of care and service. Support continuum of member care by identifying members in need of health education, case management, etc.
Educates providers and office staff on proper coding and billing practices, HEDIS and state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria.

Other responsibilities include:

• Solicit identification of barriers the office faces in providing care to members.


• Supports the HEDIS medical record chase to support optimum HEDIS and quality metric reporting


• Supports quality improvement program studies requesting records from providers, maintaining databases, and researching to identify members' provider encounter history


• Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned


• Performs annual medical record evaluation, follow-up education, practitioner intervention, measurement as required


• Enter documentation of findings in identified database


• Generally works independently, under the supervision of the Quality Management leader


• Participates in or coordinates with other department projects as needed


• Ability to travel within the state of Mississippi. Some overnight travel required

Skills / Requirements

• Clinical Registered Nurse with current licensure required


• 5+ years clinical experience, or other relevant experience


• 2+ years of quality improvement experience, or other relevant experience


• Experience working in Medicaid and/or Medicare health care and insurance industry, including regulatory and compliance requirements


• Bachelors degree in Science or equivalent work experience required; Masters degree preferred


• Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry.


• Ability to travel to physician offices; valid state-specific driver's license and reliable vehicle.


• Strong organizational skills and ability to work both independently and with teams.


• Ability to evaluate medical records with attention to detail.


• Ability to interact with medical staff, peers, and internal company staff at all levels.


• Ability to make formal presentations in front of committee and work group environments.


• Ability to use databases and prepare reports as needed


• Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint


• Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance and achieve targets


• Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action


• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.


• Ability to travel within the state of Mississippi. Some overnight travel required.


• Consultant, marketing or teaching experience a plus


• Knowledge of CPT and ICD-9 coding and physician billing a plus.

UnitedHealthcare Community & State is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.

If you're ready to help make health care work better for more people, you can make a historic impact on the future of health care at UnitedHealthcare Community & State.

We contract with states and other government agencies to provide care for over two million individuals. Working with physicians and other care providers, we ensure that our members obtain the care they need with a coordinated approach.

This enables us to break down barriers, which makes health care easier for our customers to manage. That takes a lot of time. It takes a lot of good ideas. Most of all - it takes an entire team of talent. Individuals with the tenacity and the dedication to make things work better for millions of people all over our country.

You can be a part of this team. You can put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered.

Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.