Job Details

Optum Insight Quality Review Operations Specialist

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale.Join us to start Caring. Connecting. Growing together.

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 solid 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.

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

Primary Responsibilities:

• Learn, understand and apply HEDIS/CMS measure knowledge to support functional operation proficiency at a market or reporting population level
• 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
• Ability to properly interpret and apply HEDIS measure knowledge to ensure compliance with quality standards
• Observe and comply with policies and procedures for assigned scope:
• Quality Assurance
• Vendor Inter-Rater Reliability (VIRR)
• Medical Record Review Validation (MRRV)
• Inter-Rater Reliability (IRR)
• Abstraction (medical chart interpretation and data entry)
• Rate maximization
• Conduct Quality Assurance work, Inter-Rater Reliability assessments on all internal abstraction staff as well as participate in Medical Record Review Validation activities:
• Identify, document and communicate trends and issues with abstraction concerns.
• Ensure all errors are identified, documented and tracked/followed through to resolution
• Ensure all charts are pulled, reviewed and documented within appropriate time frames to support final MRRV audits, supporting any corrective action plans as required
• Claims research and activation of chases to pursue specific data components that could lead to compliance
• Support and participate in process improvement/debrief initiatives
• Conduct year-round abstraction and IRR activities for all projects (within volume scope)
• Engage in training development, UAT and beta testing, as appropriate
• 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).
• 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.
• Completion of all required measure-level, systems and process trainings within designated timelines
• 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
• 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
• Occasional outreach to provider offices to support timely and complete medical record retrieval during production season and gap closure during the pre-season
• Surveillance of vendor and contractor abstraction activities to determine accuracy
• 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
• Exhibits creative problem-solving skills, adapting approach as needed for each engagement
• Demonstrates adaptability in a highly changing environment, quickly and effectively shifting focus as priorities change
• Ability to meet team and departmental productivity expectations while maintaining quality standards
• Ability to work extended hours during peak season(s) to ensure departmental goals are met

Required Qualifications:

• 2+ years of Medical Terminology Experience
• 1+ years of medical record review experience
• 1+ years Healthcare industry or managed care experience
• Intermediate level of proficiency with Microsoft Word, Excel, and PowerPoint
• Demonstrated ability to work nights and/or weekends during peak seasons as needed
• No travel Required

Preferred Qualifications:

• Undergraduate degree in Medical Sciences/Public Health
• 2+ years direct HEDIS Hybrid datamining experience
• Clinical and/or Health Education experience
• Experience working with provider offices (clinician and non-clinicians)
• Knowledge of HEDIS, CMS STARs and NCQA reporting guidelines
• Experience using Microsoft Visio, SharePoint, Excel
• 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
• Demonstrated energy, motivation, and commitment to drive to results in a challenging, fast-paced environment
• Proven diplomatic with solid conflict resolution skills and emotional resilience

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, New York, Rhode Island, or Washington Residents Only: The hourly range for California, Colorado, Connecticut, Nevada, New York, Rhode Island or Washington residents is $27.07 to $53.08. 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 employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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