Job description
We support providers who care for UnitedHealthcare (UHC) Medicaid and CHIP members across five counties in southeastern Pennsylvania: Philadelphia, Montgomery, Bucks, Chester, and Delaware. Our team includes a Clinical Quality Manager, a Quality Director, and a Quality Nurse. This role will serve as the second Quality Nurse on the team. Within our same department we have a member outreach team also and another responsible for NCQA policy and Performance Improvement Projects.
Our primary goal is to promote our local Pay‑for‑Performance program and support providers in achieving the highest possible incentive outcomes by meeting HEDIS® and state quality measures. In addition, we provide ongoing support to provider groups engaged in value‑based contracts, which also include HEDIS® and state‑mandated quality measures tied to defined performance benchmarks.
You'll enjoy the flexibility to work remotely * within Montgomery and surrounding counties as you take on some tough challenges.
Responsibilities
- Quality Program Leadership & Provider Support
Oversee ongoing provider practice engagement and community education related to state specific quality measures
Collaborate closely with the Quality Manager and Quality Director to coordinate an interdisciplinary approach that improves provider's performance
Serve as the primary resource for provider focused clinical quality improvement and management programs
Educate providers and office staff on quality program requirements, including analysis of provider level outcomes, monitoring of key metrics, and support in meeting quality standards, contractual obligations, and pay for performance targets
Clinical Quality & Compliance
Ensure activities align with State, CMS, NCQA, and other regulatory requirements
Support providers in evaluating member care, identifying care gaps, and developing action plans using evidence based guidelines and quality tools (HEDIS®, NCQA, CMS, state specifications)
Conduct onsite medical record audits to assess coding, documentation, quality compliance, and service delivery standards
Investigate documentation gaps or system issues impacting measure performance, provide feedback, and monitor resolution to completion
Data Analysis, Reporting & Record Management
Analyze quality data to identify trends, opportunities for structured data, and gaps in care at the provider and member levels
Maintain care opportunity reports, track encounter history, and support quality related studies or initiatives as directed by the Health Plan
Support medical record collection and abstraction processes for Pre Season (April-January), Hybrid (January-April), PAPM Maternity (April-July) and other review periods to optimize measurement and reporting
Prepare and distribute reporting, and analytics related to care gaps, performance trends, and member outreach opportunities
Provider Practice Transformation & Education
Lead targeted practice level quality improvement initiatives through clinical education and deployment of approved materials
The role assists contracted providers with analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS®, CMS, NCQA and other tools
Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring, and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives based on HEDIS® measures
Deliver training on documentation, coding, billing, state mandated quality metrics, profiling, pay for performance methodologies, and medical record review criteria
Serves as subject matter expert (SME) for assigned HEDIS®/ State 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® / State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS®/State Measure rates
Care Gap Closure & Targeted Quality Improvement
Drive closure of open care opportunities, including preventive services, chronic condition management, and other quality measures through HEDIS® data collection
Identify population level barriers to care and recommend evidence based strategies to close clinical gaps and improve outcomes
Provide follow up education or interventions for practitioners based on chart audit findings to support continuous quality improvement
Relationship Management & Community Engagement
Build and maintain solid relationships with internal and external stakeholders, including providers, practice staff, community organizations, and public health partners
Participates, coordinates, and/or represents the Health Plan at community-based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
Document and escalate non clinical or service related provider concerns to appropriate departments (Provider Relations, Chief Medical Officer, etc.)
Operational & Cross Functional Collaboration
Coordinate with other departments on projects and initiatives that intersect with quality performance, regulatory activities, or provider engagement
Work independently and within a highly matrixed team environment, managing competing priorities while meeting deadlines
Perform additional duties as assigned by Quality Leadership
Challenges of the role
This Role Can Be Challenging For Individuals Who
Struggle with managing multiple priorities at once, as quality work often involves juggling several projects, deadlines, and stakeholders simultaneously
Are not naturally self sufficient or self motivated, since the role often requires taking initiative, problem solving independently, and driving improvements without constant direction
Are uncomfortable working with data, including reviewing and analyzing information in Excel, running or interpreting reports, and creating clear, professional presentations
Do not feel confident presenting information or speaking in public, as sharing findings with leadership, committees, or clinical teams is a core part of the work
Prefer routine, predictable tasks, because quality roles frequently shift based on organizational needs, audit findings, or emerging quality concerns
Have difficulty navigating change, as the job involves implementing new workflows, policies, and performance improvement initiatives across teams
Are uncomfortable giving feedback or addressing performance gaps, even in a constructive, supportive way
Do not enjoy collaborating across multiple departments, since relationship building with clinicians, leadership, and operational partners is essential
Struggle with regulatory or compliance details, as the role requires understanding, interpreting, and applying standards from accrediting and regulatory bodies
Have trouble documenting processes, writing summaries, or communicating findings clearly and concisely
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.
Requirements
- Required Qualifications: Registered Nurse licensure in the state of PA
Experience in clinical quality, patient safety, risk management, or performance improvement
Experience leading or facilitating performance improvement within scope
Knowledge of HEDIS® measures technical specifications
Familiarity with quality measurement tools, such as dashboards, scorecards, databases, or EHR reporting tools
Intermediate proficiency in Microsoft Office applications, particularly Excel and PowerPoint
Demonstrated solid documentation and organization skills
Willingness to travel to community-based events for assigned groups up to 10%
Driver's License and access to reliable transportation
Key Competencies: Attention to detail and accuracy
Critical thinking and clinical judgment
Collaboration and relationship building
Ability to educate providers or administrative staff and provide feedback constructively on performance
Adaptability and comfort with change
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
About UnitedHealthcare
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
