Senior Clinical Quality RN - Remote

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Positions in this family require a current, unrestricted nursing license in the applicable state, as indicated in the function description and/or job title.

Positions in this function include RN roles (with current unrestricted licensure in applicable state) responsible for clinical quality audits and peer reviews.

• Reviews the work of others
• Develops innovative approaches
• Sought out as expert
• Serves as a leader/ mentor

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

Primary Responsibilities:

• Anticipates customer needs and proactively develops solutions to meet them
• Serves as a key resource on complex and/or critical issues
• Solves complex problems and develops innovative solutions
• Performs complex conceptual analyses
• Reviews work performed by others and provides recommendations for improvement
• Forecasts and plans resource requirements
• Authorizes deviations from standards
• May lead functional or segment teams or projects
• Provides explanations and information to others on the most complex issues
• Motivates and inspires other team members

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 Qualification:

• Undergraduate degree or equivalent experience

Functional Competency & Description

CQM_Review/Research Clinical Documentation

• Review technical metrics/specifications/measures -Evaluate documentation of medical care
• Review/interpret medical records/data to determine whether there is documentation that medical services were rendered -Determine/verify whether or not preventative services were rendered
• Identify members requiring additional follow-up (e.g., referral to Case Management)
• Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC)
• Run/pull/prioritize relevant data/reports (e.g., member level data, geographical trends, provider data)
• Prioritize providers for medical chart review (e.g., high volume members not seen)
• Manipulate and leverage multiple databases/Electronic Medical Records applications(e.g., provider panels, medical review databases) to sort, search, and enter information
• Identify incomplete/inconsistent information in medical records and label missing measures/metrics/concerns

CQM_Analyze Clinical Documentation and Make Referrals

• Review relevant HEDIS specifications to guide chart review
• Review/interpret/summarize medical records/data to address quality of care questions -Generate reports/findings of reviews
• Review provider responses to reports/findings and correlate with medical records
• Review/verify medical claims coding
• Review medical records for compliance with regulatory guidelines (e.g., NCQA, state Medicaid contracts, Clinical Practice Guidelines)
• Verify necessary documentation is included in medical records
• Maintain HIPAA requirements for sharing minimum necessary information
• Based on review of clinical data/documentation, identify potential quality of care issues (e.g., variations from standard practice potentially resulting in adverse outcomes) and potential fraud/waste/abuse.
• Refer issues identified to relevant parties (e.g., review committee, Case Management, Medical Directors) for further review/action
• Apply knowledge of relevant peer review protection, reporting requirements, and confidentiality policies, procedures and regulations

CQM_Develop/Implement Action Plans/Follow Up

• Talk to provider offices to address corrective action plans
• Talk to provider offices about member service needs or care rendered
• Educate provider representatives/office staff to address/improve processes/reduce recurring problems
• Provide technical guidance to providers to improve/standardize quality of care
• Assist provider/office staff in developing strategies for increasing member adherence with preventative or other support services
• Refer inconsistencies/problems with medical claims coding to appropriate parties for resolution (e.g., claims department)
• Educate providers on proper medical record documentation for regulatory compliance
• Educate others on technical metrics/specifications/measures
• Explain/convey technical specifications regarding action plans/follow up and adjust communication to level of audience -Explain how provider scores are calculated/determined
• Direct activities/target outreach to increase quality scores (e.g., STAR ratings)
• Initiate action when preventative services are not rendered as planned

CQM_Demonstrate Business/Industry Knowledge

• Demonstrate knowledge of healthcare insurance industry products (e.g., HMO, PPO, ASO)
• Demonstrate knowledge of Medicare and Medicaid benefit products including applicable state regulations
• Demonstrate knowledge of applicable area of specialization (e.g., rehab, pediatric, home care, home and community based services)
• Acquire proficiency in utilizing multiple medical record systems to obtain relevant data
• Leverage relevant search engines and data capture software (e.g., HEDIS, HCC)
• Demonstrate knowledge of computer functionality, navigation, and software applications (e.g., Windows, Microsoft Office applications, phone applications, fax server)
• Demonstrate knowledge of specific software applications associated with the job function (e.g., navigation of relevant computer applications or systems, intranet databases, records management or claims databases)
• Provide input into development of systems/databases to capture metrics/measures

CQM_Drive Effective Clinical Decisions within a Business Environment

• Asks critical questions to ensure member/customer centric approach to work
• Identifies and considers appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
• Utilizes evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
• Identifies and implements innovative approaches to the practice, in order to achieve or enhance quality outcomes and financial performance
• Uses appropriate business metrics (e.g. member/FTE, length of stay, readmission rates, STAR ratings, member engagement rates) and applicable processes/tools (e.g. cost benefit analysis, return on investment, proforma, staffing calculator) to optimize decisions and clinical outcomes
• Prioritizes work based on business algorithms and established work processes, or in their absence, identifies business priorities and builds consensus to triage and deliver work (e.g. assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up.)
• Understands and operates effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state.)

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.

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.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

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

Employers have access to artificial intelligence language tools (“AI”) that help generate and enhance job descriptions and AI may have been used to create this description. The position description has been reviewed for accuracy and Dice believes it to correctly reflect the job opportunity.