Job was saved successfully.
Job was removed from Saved Jobs.

Job Details

UnitedHealth Group

ACO Quality and Transformation Mgr - Telecommute in CT, RI, MA, ME, NH


Emergency and Trauma


Warwick, Rhode Island, United States

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

The ACO Quality and Transformation Manager (QTM) is responsible for the ongoing management of Quality Initiatives with physician practices participating in UnitedHealthcare’s (UHC) Accountable Care Organizations (ACO). The selected candidate will be responsible for strategically developing clinically oriented partnerships with ACOs and their participating providers in order to increase quality scores based on state specific quality measures. This role will collaborate with matrix partners on ongoing management of provider practice and community education on state specific quality measures. You will work to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the ACO and provider levels, monitoring, measuring, and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. You will focus on tasks that occur in accordance with State, CMS, or other requirements as applicable. This role will analyze member care, trending quality compliance and create action plans and programs to ACO in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS and other tools.

Position reports to the Northeast Associate Director of Value-Based Systems of Care within United Clinical Services Population Health division.

This is a field-based role with a home-based (telecommute, work at home) office. You will be spending up to 25% of the time in the field within an assigned coverage area. Candidates must be willing to travel within the New England area and markets within the Northeast Region as needed.

If you are located in CT, RI, MA, ME, or NH, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Serves as subject matter expert (SME) for assigned HEDIS / CMS measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS / CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS / CMS Measure rates
  • Identify patient care opportunities and collaborate with ACO’s physician practices to ensure appropriate member appointments and care
  • Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
  • Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion
  • Educates providers and office staff on proper clinical documentation, coding, and billing practices, CMS mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
  • Documents and refers providers' non-clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
  • Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with CMS specific measures and technical specifications
  • Build and effectively maintain relationship with the practice leadership and key clinical influencers actively involved in quality
  • Regularly facilitate efficient, effective quality improvement meetings with the practice to monitor, present, and discuss progress on the action plan and achievement in milestones

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:

  • Bachelor's degree or equivalent relevant experience
  • 2+ years of quality improvement experience to include but not limited to STARs and HEDIS
  • Experience working with Medicare
  • Experience in interpreting and utilizing data to drive change
  • Experience working with and collaborating successfully with senior level leadership
  • Demonstrated experience leading groups and solid presentation skills
  • Sound Microsoft Office Skills with Word, Excel, and PowerPoint
  • Access to high-speed internet for home office set up
  • Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area (require valid driver’s license)
  • Willingness to travel up to 25% for face-to-face meetings (varies by market)
  • Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifcations:

  • Master's Degree
  • Active Certified Professional Coder (CPC) certification or current enrollment in the program
  • Active Certified Risk Adjustment Coder (CRC) certification or current enrollment in the program; or Active Certified Professional Coder (CPC) certification or current enrollment in the program
  • 2+ years of physician chart review experience impacting diagnosis coding on risk adjustment payment models
  • Experience preparing and presenting information to clinical and executive level leadership
  • Health care and insurance industry experience, including regulatory and compliance
  • Experience implementing Clinical and Quality initiatives designed to help provider or hospital groups achieve large-scale quality goals
  • Knowledge of one or more of: clinical standards of care, preventive health standards, governing and regulatory agency requirements, and the managed care industry

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 5 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)

Connecticut Residents Only: The salary range for Connecticut residents is $90,500 to $161,600. 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.

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

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.