Senior Clinical Quality RN- Remote in PA

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

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.

Primary 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.

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
  
  

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.