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Clinical Review Oversight Specialist - Telecommute in Minnetonka, MN

Company: UnitedHealth Group
Location: Orlando
Posted on: August 6, 2022

Job Description:

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)

Clinical Review Oversight Specialist is responsible for performing abstraction and overread to close gaps in care for prospective projects PSDC and GRPRO. -During Retrospective HEDIS - key activities required by auditor to perform QA of abstraction vendors to identify critical errors and increase STAR and accreditation ratings as well as abstract and overread state specific measures.

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 during HEDIS - collection season includes oversight of medical record abstraction and overread.

If you are located within Minnetonka, MN you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:


  • Responsible to understand and apply knowledge to support and deliver HEDIS -/ CMS measure 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) -


    • Ensure all charts are pulled and documented to support final MRRV audits
    • Support and participate in process improvement/debrief initiatives -
    • Conduct year-round abstraction and IRR activities for all charts collected internally (within volume scope) -
    • Engage in training development, UAT and beta testing, as appropriate
    • Understanding of additional quality programs such as PSDC and GRPRO in order to effectively support medical record collection based on unique components of these projects -
    • 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 timeframes -
    • Reporting and monitoring trends to improve HEDIS - and HEDIS - like state specific measures -
    • Basic understanding of project management concepts such as project scope, project charters, stakeholders, timeliness, and project management tracking tools -
    • Ability to meet timelines associated to project tasks and/or diligence in expressing risks, issues and dependencies -
    • Consistently maintain an accurate, detailed and up to date repository of provider relationships, medical record collection method details and access -
    • Medical record abstraction 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 -
    • Oversight of vendor 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
    • Ability to identify, adjust to and adapt to alternate methods of completing assignments when/as needed
    • Demonstrates adaptability in a highly changing environment, quickly 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 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:


      • Undergraduate degree in Medical Sciences/Public Health or 4+ years equivalent relevant work experience -
      • 4+ years of Medical Terminology Experience -
      • 4+ years of medical record review experience -
      • 4+ years Healthcare industry or managed care experience -
      • 2+ years direct HEDIS - Hybrid datamining experience -
      • Intermediate level of proficiency with Microsoft Word, Excel and PowerPoint -
      • Ability to work nights and/or weekends during peak season (February- June) as needed -
      • No travel Required -


        Preferred Qualifications:


        • Clinical and/or Health Education experience -
        • Experience working with provider offices (clinician and non-clinicians) -
        • Experience using Microsoft Visio, SharePoint, Excel -
        • Knowledge of CMS STARs -
        • Effective interpersonal and communication skills, both written and verbal -
        • Energy, motivation, and commitment to drive to results in a challenging, fast-paced environment -
        • Diplomatic with solid conflict resolution skills and emotional resilience -
        • Ability to meet commitments, build consensus, negotiate resolutions, and garner respect from other teams -
        • Ability to assist with focusing activities toward a strategic direction and achieve targets /goals -
        • 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



          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 at UnitedHealthcare Medicare & Retirement. The Boomer generation is the fastest growing market segment in health care. And we are the largest business in the nation dedicated to serving their unique health and well-being needs. Up for the challenge of a lifetime? Join a team of the best and the brightest to find bold new ways to proactively improve the health and quality of life of these 9 million customers. You'll find a wealth of dynamic opportunities to grow and develop as we work together to heal and strengthen our health care system. Ready? It's time to do your life's best work.(sm)

          *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.

Keywords: UnitedHealth Group, Orlando , Clinical Review Oversight Specialist - Telecommute in Minnetonka, MN, Healthcare , Orlando, Florida

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