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Clinical Practice Performance Consultant Auditor - California

Sacramento, CA

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Job DescriptionnThe Registered Nurse CPC/FSR Nurse will work closely with the Director of Clinical Quality and other internal and external stakeholders to coordinate an interdisciplinary approach to increased provider performance and compliance to State standards regarding the Facility Site Review program. The person in this position is responsible for strategically developing clinically oriented provider and community based partnerships in order to: 1) increase quality scores based on California quality measures; and 2) to complete DHCS facility site, medical record and physical accessibility reviews. The person in this position is responsible for ongoing management of provider practice and community education on California quality measures. This role includes planning and devliering provider education regarding the Quality Improvement program including analysis and review of quality outcomes at the provider level; monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. The Registered Nurse CPC/FSR Nurse will focus on tasks that occur in accordance with State (DHCS and DMHC), CMS, NCQA, and/or other requirements as applicable. The role assists contracted providers with preparing for Faciity Site Reviews, analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved DHCS auditing tools, clinical practice guidelines, HEDIS, CMS, NCQA and other resources. Position will be responsible for coordinating visits and administrative functions associated with the site reviews.If you are located in San Diego or Sacramento, CA, you will have the flexibility to telecommute* as you take on some tough challenges. This position requires travel to physician offices in San Diego or Sacramento up to 75% of the time.Primary Responsibilities:Complete Facility Site, Medical Record Reviews, and Physical Accessibility Reviews Education and Engagement of Practice-Level Leadership Targeted Quality Improvement Activities Medical Record Review to Identify HEDIS Care Gap Closures Relationship Management - Internal and External Community Engagement and Interaction Provider and Practice Education, Quality Oriented Health Topics Data Entry; Administrative Functions to Facilitate the Facility Site Review Process Policy Review; Development of Standard Operating Procedures Audit Preparation and Representation for Regulatory AuditsRequired Qualifications:Current unrestricted RN licensure required in the state of operation 5 years clinical experience, or other relevant experience 1 years of experience reviewing medical records within a regulatory  audit capacity DHCS Facility Site Reviewer Certification or ability to obtain within 12 monthsPreferred Qualifications:Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing, regulatory agency and facility requirements, and the managed care industry 2 years of quality improvement experience, or other relevant experience Experience working in Medi-Cal and/or Medicare Health care and insurance industry experience, including regulatory and compliance Bachelor’s degree or higher in Science or related field DHCS Master Trainer Certification Experience communicating effectively with broad audience including Physicians, nurses, non-clinical office staff, and across the Health Plan Strong organizational skills and ability to work both independently and with teams Experience working in a collaborative environment with ability the to influence others and build strong professional relationships Experience with making formal presentations within the context of their role Experience using databases to input information and prepare reports as needed Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPointCareers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)*All Telecommuters will be required to adhere to **MEMBERS ONLY**SIGN UP NOW***.’s Telecommuter Policy.Diversity creates a healthier atmosphere: **MEMBERS ONLY**SIGN UP NOW***. 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.**MEMBERS ONLY**SIGN UP NOW***. is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.Job Keywords: CPC, Clinical Practice Consultant, Auditor, RN, Registered Nurse, HEDIS, Quality, DHCS, DMHC, CMS, NCQA, site reviewer, Medi-Cal, Medicare, San Diego, Sacramento, CA, California, Telecommute, Telecommuter, Telecommuting, Remote

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