Job Description

WellMed, part of the Optum family of businesses, is seeking a RN, Clinical Quality Consultant to join our team in San Antonio, TX. 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. 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 Clinical Quality Consultant will drive consistency, efficient processes and share best practices – in a collaborative effort with the providers – designed to facilitate a minimum 4 STAR rating. The CQC will participate in quality improvement initiatives, 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.

Position Highlights & Primary Responsibilities:

• Develop market business plans to motivate providers to engage in improving Stars measures to be 4 STARS or higher
• Provide analytical interpretation of Stars and HEDIS reporting, including executive summaries to plan and provider groups
• Be the primary go to person for all STARS related activities within their assigned market(s) working within a matrix relationship which includes Quality corporate operations and Regional/Market operations
• Assist in developing of training and analytical materials for Stars and HEDIS
• Lead or participate and present in weekly, Monthly, Bi-monthly, Quarterly and/or Annual business Review meetings related to STAR activities which summarize provider group performance and market performance as requested by or required by Quality or Regional leadership
• Analyze and evaluate provider group structure and characteristics, provider group/provider office operations and personnel to identify the most effective approaches and strategies
• 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

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.

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:

• Registered Nurse (within the states in which service is being delivered) with undergraduate degree or (4 years equivalent experience above and beyond the required years of experience may be considered in lieu of undergraduate degree)
• 4+ years of associated business experience within the health care industry including experience with HEDIS/Stars
• Previous experience influencing others resulting in changes in behavior (preferably with providers in various care delivery models)
• Solid knowledge of the Medicare market, products and competitors
• Knowledge base of clinical standards of care, preventative health, and Star measures
• Experience in managed care working with network and provider relations
• Financial analytical background within Medicare Advantage or government programs (Risk Adjustment/STARS Calculation models)
• Previous experience in provider-facing HEDIS strategy and education
• Experience presenting education of HEDIS/Stars material to providers and provider office staff
• Microsoft Office specialist with exceptional attention to detail; must be proficient with Excel
• 50 – 75% local travel required, with occasional overnight travel

Preferred Qualifications:

• Undergraduate degree
• Post graduate degree
• Billing and CPT coding experience
• Clinical data abstraction experience
• Solid business acumen, especially as it relates to Medicare
• Medical/clinical background
• Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
• Solid communication and presentation skills
• Solid relationship building skills with clinical and non-clinical personnel
• Ability to solve process problems crossing multiple functional areas and business units
• Solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
• Adaptable to change
• Excellent customer service skills

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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