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Job Information

UnitedHealth Group Clinical HEDIS SME - Remote in Washington, District Of Columbia

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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)

The Clinical SME, Client Engagement and Training Operations within the Risk Quality and Provider Enablement division of OptumInsight, provides clinical expertise to abstraction teams for HEDIS® Supplemental and Chart Chase. They will be responsible for quality audits, individual quality monitoring, participating in training, building training and support materials for abstractors and clients.

Demonstrated HEDIS® subject matter expertise for retrospective, prospective and administrative measures is essential to job performance. In addition, SME will provide essential support with reporting and audit submissions

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

Primary Responsibilities:

  • Participate in HEDIS® audits

  • Participate in the development of HEDIS® Medical Record Review training materials

  • Participate in training resources and clients on HEDIS® medical record review

  • Experience working in a matrix environment

  • Serve as the Subject Matter Expert of NCQA’s HEDIS® Technical Specifications for all HEDIS® Hybrid Measures

  • Provide leadership and insight related to the MRR Vendor Training Programs and Policies and Procedures

  • Ensure Quality Assurance (QA) standards are met at the measure level through vigorous oversight and Inter-Rater Reliability (IRR) of chart abstractions performed on behalf of the client by MRR Vendors

  • When quality issues are identified, work hand in hand with the vendor to close the gap and ensure that quality assurance levels return to expected levels of acceptability

  • Conduct oversight of numerator positive charts selected for MRRV Audit

  • Provide leadership in the HEDIS® MRRV chart preparation and submission preparation for HEDIS® Auditors

  • Participate in correction of any and all errors identified as part of the MRRV Audit to ensure all errors are corrected and re-submitted timely

  • Assist in managing customer expectations, and provide critical feedback to software development personnel

  • Provide strategic support in preparation of the HEDIS® Roadmap, HOQ, and HEDIS® audit

  • Provide feedback related to annual system updates for MRR abstraction tool as result of specification changes and/or process enhancements

  • Point of contact for HEDIS® auditors for system demos and onsite interviews

  • Participate in developing/pulling reporting documents for progress and results of abstraction

  • Cultivate and build relationships by providing client satisfaction through effective listening to client needs and providing tailored solutions which results in successful client engagement

  • Participate in weekly client calls to represent the clinical operations team serving as a liaison and subject matter expert of the programs we support as needed

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:

  • Associates degree

  • Clinical Licensure such as LPN, RN, RRT, etc.

  • 2+ years of experience in a health care delivery organization

  • 2+ years of HEDIS® experience, performing a wide range of functions with solid focus on medical record review and clinical oversight

  • Knowledgeable of current trends in HEDIS® in managed health care

  • Knowledgeable of NCQA, Stars, HEDIS®, HOS and CAHPS requirements

  • Familiarity with ICD-9-CM, CPT, DRG, LOINC, HCPCS, TOB, POS, NDC coding

  • Basic proficiency with Microsoft Office Suite (Word, Excel, PowerPoint)

Preferred Qualifications:

  • Proficiency in presentation skills to audiences of various sizes

  • Knowledge of Medicaid and/or Medicare programs

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 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.

Colorado, Connecticut, Nevada, or New York City Residents Only: The salary range for Colorado residents is $66,100 to $118,300. The salary range for Connecticut/Nevada/New York City residents is $72,800 to $129,900. 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

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.