You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

The Optum Insight Quality Review Operations (QRO) Specialist will be responsible for ongoing operational support to commercial clients / reporting populations to achieve client HEDIS ® goals.

This role will be responsible for ongoing support of market/reporting population specific quality measures. The QRO Specialist will work to strategically increase HEDIS ®, CMS STARs and state- specific measure performance scores by monitoring, measuring and reporting on key metrics to meet or exceed quality standards, contractual requirements and pay for performance incentives. This role is dedicated to Optum Insight.

Individual must be highly organized, possess strong critical thinking skills, with demonstrated professional maturity and emotional resilience. Day to day work varies based on time of year, with overarching goal to increase collection of member compliant information resulting in improved HEDIS® rates. The core work includes medical record abstraction, over read, and rate maximization.

This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 8:00am – 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends.

• All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

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  Responsible to learn, understand and apply HEDIS/CMS measure knowledge to support functional operation proficiency at a market or reporting population level
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  Ability to work in a self-directive manner and apply critical thinking/problem solving skills by referencing available Technical Specifications, Business Process Documentation, Job Aids and other tools for clarity/guidance as needed
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  Ability to properly interpret and apply HEDIS measure knowledge to ensure compliance with quality standards
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  Observe and comply with policies and procedures for assigned scope:
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  Quality Assurance
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  Vendor Inter-Rater Reliability (VIRR)
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  Medical Record Review Validation (MRRV)
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  Inter-Rater Reliability (IRR)
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  Abstraction (medical chart interpretation and data entry)
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  Rate maximization
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  Conduct Quality Assurance work, Inter-Rater Reliability assessments on all internal abstraction staff as well as participate in Medical Record Review Validation activities:
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  Identify, document and communicate trends and issues with abstraction concerns.
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  Ensure all errors are identified, documented and tracked/followed through to resolution
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  Ensure all charts are pulled, reviewed and documented within appropriate time frames to support final MRRV audits, supporting any corrective action plans as required
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  Claims research and activation of chases to pursue specific data components that could lead to compliance
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  Support and participate in process improvement/debrief initiatives
  
• Conduct year-round abstraction and IRR activities for all projects (within volume scope)
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  Engage in training development, UAT and beta testing, as appropriate
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  Understanding of additional quality HEDIS® aligning with NCQA Technical Specifications to effectively support medical record collection, abstraction and overread based on unique components of the project(s).
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  Understanding of HEDIS® or other quality program project progress and results in order to prioritize collection to meet financial and timeline targets which requires the ability to be agile and shift priorities sometimes daily.
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  Completion of all required measure-level, systems and process trainings within designated timelines
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  Reporting and monitoring trends to improve HEDIS® and HEDIS®-like state specific measures
  
• Ability to meet timelines associated to project tasks and/or diligence in expressing risks, issues and dependencies
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  Assist with orienting partner resources via job shadowing, demonstration of tasks and systems, and performing quality checks
  
• Medical record collection, abstraction, overread, Ratemax and data entry support, as needed
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  Occasional outreach to provider offices to support timely and complete medical record retrieval during production season and gap closure during the pre-season
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  Surveillance of vendor and contractor abstraction activities to determine accuracy
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  Identify / participate in pre-season (non- hybrid season) data collection activities and regional or state-specific projects to identify operational improvements, trends in performance, other opportunities to improve HEDIS® scores, CMS Star Ratings and other metrics
  
• Builds trust and forms effective relationships with stakeholders by providing timely operational updates, partnering on issue resolution/mitigation strategies, and monitors resolution of identified issues to conclusion
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  Exhibits creative problem-solving skills, adapting approach as needed for each engagement
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  Demonstrates adaptability in a highly changing environment, quickly and effectively shifting focus as priorities change
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  Ability to meet team and departmental productivity expectations while maintaining quality standards
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  Ability to work extended hours during peak season(s) to ensure departmental goals are met

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:

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  Bachelor's Degree (or higher) in Medical Sciences/Public Health or 2+ years equivalent relevant work experience
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  2+ years of Medical Terminology Experience
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  2+ years direct HEDIS® Hybrid datamining experience
  
• 4+ years of medical record review experience
  
• 1+ years of Healthcare industry or managed care experience
  
• Intermediate level of proficiency with Microsoft Word, Excel and PowerPoint
  
• Ability to work nights and/or weekends during peak seasons as needed including the flexibility to work occasional overtime per business need
  

Preferred Qualifications:

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  Clinical and/or Health Education experience
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  Experience working with provider offices (clinician and non-clinicians)
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  Knowledge of HEDIS, CMS STARs and NCQA reporting guidelines
  
• Experience using Microsoft Visio, SharePoint, Excel

Telecommuting Requirements:

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  Required to have a dedicated work area established that is separated from other living areas and provides information privacy
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  Ability to keep all company sensitive documents secure (if applicable)
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  Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

Soft Skills:

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  Effective interpersonal and communication skills, both written and verbal
  
• Demonstrated ability to meet commitments, build positive consensus, negotiate resolutions, and garner respect from other teams
  
• Demonstrated ability to assist with focusing activities toward a strategic direction and achieve targets /goals
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  Energy, motivation, and commitment to drive to results in a challenging, fast-paced environment
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  Diplomatic with strong conflict resolution skills and emotional resilience

UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.

Military & Veterans find your next mission: We know your background and experience is different and we like that. UnitedHealth Group values the skills, experience and dedication that serving in the military demands. In fact, many of the values defined in the service mirror what the UnitedHealth Group culture holds true: Integrity, Compassion, Relationships, Innovation and Performance. Whether you are looking to transition from active duty to a civilian career, or are an experienced veteran or spouse, we want to help guide your career journey. Learn more at https://uhg.hr/transitioning-military

Learn how Teresa, a Senior Quality Analyst, works with military veterans and ensures they receive the best benefits and experience possible. https://uhg.hr/vet

Careers with OptumInsight. Information and technology have amazing power to transform the Healthcare industry and improve people's lives. This is where it's happening. This is where you'll help solve the problems that have never been solved. We're freeing information so it can be used safely and securely wherever it's needed. We're creating the very best ideas that can most easily be put into action to help our clients improve the quality of care and lower costs for millions. This is where the best and the brightest work together to make positive change a reality. This is the place to do your life’s best work.SM

Colorado, Connecticut, Nevada or New York City Residents Only: The salary range for Colorado residents is $26.15 - $46.63. The salary range for Connecticut / Nevada / New York City residents is $28.85 - $51.30. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Diversity creates a healthier atmosphere: UnitedHealth Group 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.

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

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