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 and help people live healthier lives while doing your life's best work.(sm)
Positions in this function include RN roles (with current unrestricted licensure in applicable state) responsible for clinical quality audits and peer reviews.
You’ll enjoy the flexibility to work remotely* from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities

• Solves moderately complex problems and/or conducts moderately complex analyses
• Assesses and interprets customer needs and requirements
• Provides explanations and information to others on difficult issues
• Coaches, provides feedback, and guides others
• Identifies solutions to non-standard requests and problems
• Translates concepts into practice
• Works with minimal guidance; seeks guidance on only the most complex tasks
• Acts as a resource for others with less experience

CQM Review/Research Clinical Documentation

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

CQM_Analyze Clinical Documentation and Make Referrals

• Review medical records for compliance with regulatory guidelines (e.g., NCQA, state Medicaid contracts, Clinical Practice Guidelines)
• Review relevant HEDIS specifications to guide chart review
• 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
• Review/interpret/summarize medical records/data to address quality of care questions -Generate reports/findings of reviews
• Maintain HIPAA requirements for sharing minimum necessary information
• Review provider responses to reports/findings and correlate with medical records -Review/verify medical claims coding
• Verify necessary documentation is included in medical records
• 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

• Direct activities/target outreach to increase quality scores (e.g., STAR ratings)
• Educate provider representatives/office staff to address/improve processes/reduce recurring problems -Provide technical guidance to providers to improve/standardize quality of care
• Talk to provider offices about member service needs or care rendered
• Explain/convey technical specifications regarding action plans/follow up and adjust communication to level of audience -Explain how provider scores are calculated/determined
• 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
• Talk to provider offices to address corrective action plans'
• Initiate action when preventative services are not rendered as planned

CQM_Demonstrate Business/Industry Knowledge

• Demonstrate knowledge of computer functionality, navigation, and software applications (e.g., Windows, Microsoft Office applications, phone applications, fax server)
• Acquire proficiency in utilizing multiple medical record systems to obtain relevant data -Leverage relevant search engines and data capture software (e.g., HEDIS, HCC)
• Provide input into development of systems/databases to capture metrics/measures
• 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)
• 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)

CQM_Drive Effective Clinical Decisions within a Business Environment

• Identifies and implements innovative approaches to the practice, in order to achieve or enhance quality outcomes and financial performance
• 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
• 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.)
• 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
• 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
• Understands and operates effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state.)

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

• Current unrestricted RN licensure in applicable state
• Undergraduate degree or equivalent experience
• 1+ years of clinical experience

Preferred Qualifications

• Integrity Value: Act Ethically
• Familiarity with NCQA/URAC standards
• Auditing experience
• Prior Authorization experience

• Demonstrated ability to comply with Applicable Laws, Regulations and Policies
• Compassion Value: Focus on Customers
• Demonstrate Integrity

• Improve the Customer Experience
• Identify and Exceed Customer Expectations
• Relationships Value: Act as a Team Player

• Demonstrate Diversity Awareness
• Learn and Develop
• Collaborate with Others
• Relationships Value: Communicate Effectively

• Listen Actively
• Speak and Write Clearly
• Influence Others
• Innovation Value: Support Change and Innovation

• Contribute Innovative Ideas
• Work Effectively in a Changing Environment
• Performance Value: Make Fact-Based Decisions

• Apply Business Knowledge
• Use Sound Judgement

Careers at OptumCare. We're on a mission to change the face of health care. As the largest health and wellness business in the US, we help 58 million people navigate the health care system, finance their health care needs and achieve their health and well-being goals. Fortunately, we have a team of the best and brightest minds on the planet to make it happen. Together we're creating the most innovative ideas and comprehensive strategies to help heal the health care system and create a brighter future for us all. Join us and learn why there is no better place to do your life's best work.(sm)
OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.
California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $56,300 to $110,400. 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

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.