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 end-to-end monitoring, measuring, and reporting of clinical effectiveness related to maintaining accreditation by nationally recognized accrediting organizations including NCQA and URAC through internal clinical appeal oversight in compliance with the organization’s established methodology and in accordance with standard operational, regulatory, accreditation and compliance processes and procedures
Validates accuracy of compliance with all regulatory requirements and clinical decision making processes
Identifies defects, gaps and root cause within UHC functional business standard processes and collaborates with business leaders to discuss opportunities and trends to drive quality improvement
Provides guidance, remediation and post follow-up through monthly or quarterly outcomes communication to mitigate operational risk of repeat corrective action plans, fines and/or penalties from regulators
Perform ad-hoc clinical projects and oversight assessments for the UHC functional business to support an audit ready team culture
Meet standard timeliness and quality expectations for all regulatory audits outlined in team annual business objectives
Serves as a key resource on complex and/or critical clinical issues for UHC functional business and Quality of Care
Provides coaching or other support as needed to encourage compliance with evidence based medicine through the identification of negative impacts to members during the appeal and grievance process
Provide data analysis and reporting to support compliance with evidence based medicine through ad-hoc quality improvement appeal projects
UHC Clinical Oversight – Appeals and Grievances
A day in the life: UHC Clinical Oversight – Appeals and Grievances
Log into computer, review daily calendar, and check email/voice messages
Prioritize daily work utilizing critical thinking skills:
Participate in monitoring activities as scheduled
Provide support and guidance to team members as needed
Data analysis as available for improvement across the UCS Clinical teams
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 remediation team to mitigate gaps and deficiencies identified through monitoring activities
Share ideas and techniques for best practices with UCS Clinical
leaders * Collaborate with remediation team on potential CMS self-identified issues and tracking as applicable
Log out of any programs/systems and computer for the da
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
Clinical operations experience in Appeals & Grievances, Utilization Management, Clinical Coverage Review, Post-Acute Clinical Management, and Medical Claims Review or health plan audit setting
5+ years of clinical nursing experience
2+ years of Commercial, Medicare, or Medicaid Managed Care Experience
Experience presenting process performance improvement data to large audiences
Demonstrated experience identifying root cause and solution development including developing and documenting corrective action plans
Proven extremely detail orientated with focus on quality improvement
Proficiency in all Microsoft Office Programs
Proven ability to identify operational process and clinical gaps in care
Proven solid interpersonal skills and communication abilities
Proven ability to be self-motivated, independently problem solve and apply critical thinking strategies
Demonstrated ability to abide by all UHC vaccination requirements
Designated workspace and access to install secure high-speed internet via cable/DSL in home
Skills You Will Develop:
Solid skills in the application of NCQA, CMS, and DMHC standards
Able to work in ever changing, fast- paced environment & maintain flexible approach to fulfilling responsibilities
Ability to use constructive criticism/ feedback to improve skills and work processes
*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 $71,200 to $112,200 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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