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 equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
Perform ad-hoc and quarterly case file review of HMO Commercial, Medicare Advantage, and Medicaid Delegated Contracted Medical Groups and provider groups within regulatory and company driven timeframes
Communicate review results, both verbally and in writing, with leadership and Clinical team
Assist in identifying behaviors that impact compliance regarding clinical processes, denial letters and all NCQA standards and regulatory requirements (DMHC, CMS, DOI, etc.)
Assist in creating correspondence, presentations and talking points intended to document findings of studies and communicate results and suggested improvement plans
Provide oversight and coaching to encourage compliance with evidence based medicine
Serve as a clinical subject matter expert on a variety of topics by the provider group and internal departments
Assist with data collection, organization, analysis and follow-up to support oversight and improvement programs
Excellent verbal and written communication skills will be required
Analyze data, identify and articulate opportunities for improvement
Escalate, as appropriate, any critical findings immediately as identified
Enhance the use of health care data to improve quality, transparency, and outcomes
A day in the life of a Delegation Clinical Oversight Support CQN
Log into computer, review daily calendar, and check email/voice messages
Prioritize daily work utilizing critical thinking skills
Consider due dates of the file selections and file review summaries
Select files, request files, download files and review files as requested based on due dates
Participate in monitoring or file build activities as scheduled
Provide support and guidance to team members as needed as the Subject Matter Expert (SME) on case file review
Attend necessary meetings and/or training sessions
Collaborate with team/department members to identify and address issues related to monitoring and results
Collaborate with the Clinical Delegation Oversight Consultants as needed to mitigate gaps and deficiencies identified through monitoring activities
Share ideas and techniques for best practices with Clinical leaders
Log out of any programs/systems and computer for the day
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 state of residence
5+ years of clinical nursing experience
2+ years of Commercial/Medicare/or
Medicaid/SNP/Managed Care Experience
Experience handling inpatient concurrent reviews
Clinical operations experience in in a PMG, IPA, Hospital and / or health plan setting
Proficiency in all Microsoft Office Programs
Proven ability to identify operational process and clinical gaps in care
Solid interpersonal skills and communication abilities
Proven ability to be self-motivated, independently problem solve and apply critical thinking strategies
Proven ability to independently research regulatory requirements and make decisions based on that research
Access to wired high speed internet
Preferred Qualifications:
Experience in application of NCQA, CMS and DMHC regulations to meet performance expectations
Experience in coverage determination criteria (i.e. Medicare Local Coverage Determination, National Coverage
Determination and MCG and/or Interqual
criteria) and medical coding (i.e. ICD-10CM, CPT, and HCPCS codes) * Demonstrated ability to plan, document, implement and monitor Quality Improvement techniques
Demonstrated ability to implement Project Management techniques
*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 $58,800 to $105,000 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.
UnitedHealth Group
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