The Senior Clinical Quality of Care RN will be responsible for conducting quality of care (QOC) investigation, review and management of the regulatory Incident/Accident/Death (IAD) portal, documenting and communicating findings from these reviews, and preparing reports or summaries for internal and external customers. This position collaborates with the Chief Medical Officer or other Medical Directors to review QOC and other investigations and ensures that QOC investigations comply with all applicable State, Federal, and regulatory requirements. These activities are used to ensure care and services provided to our members are timely, adequate, and compliant with regulatory and professional standards and guidelines.
These QOC investigations are specific to Arizona Medicaid and Medicare members.
This position is an Arizona based remote position with the option of working 40% in-office. There is travel up to 25% of the time based on business needs. In-office may be required based on performance metrics. The office is located at 1 East Washington Street in Phoenix.
If you reside in Arizona and be able to travel 25% of the time, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:- Perform clinical documentation review of inpatient and outpatient care delivered to adults and children with Medicaid, Medicare health care benefits through Arizona United Health Care Community Plans for peer review and internal investigations of Quality of Care concerns
- Create professionally written case investigation summaries for Peer Review, present case summaries at the Provider Advisory Committee as applicable
- Review plans of correction from providers in response to a substantiated QOC occurrence
- Effectively interface with external customers, facilities and providers to resolve quality of care concerns, obtain medical records and other information
- Conduct delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare. This includes reviewing samples of contractor work against an audit tool or information found in medical charts
- Collaborate internally with Medical Directors and staff in other UHCCP departments
- Manage multiple tasks and projects and changing priorities; prioritize work products effectively
- Maintain timeliness for deliverables and regulator requests
- Must have the ability to work independently, good critical thinking skills, excellent verbal and written communication skills
- Occasional on-site provider visits may be required for potential Quality of Care concerns
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:- Active, unrestricted RN license in the state of Arizona
- 5+ years of experience working as a Registered Nurse
- 2+ years of hospital experience as a Registered Nurse
- Experience evaluating and auditing medical records
- Proven intermediate skills in Microsoft Office, Word, and Excel ability to work with multiple data bases to retrieve and enter information
- Ability to travel up to 25% within the state of Arizona
- Driver's license and access to reliable transportation
- Reside within the state of Arizona
Preferred Qualifications:- Quality Management experience in a healthcare setting
- Experienced with Behavioral Health Services
- Experience analyzing information and preparing written summaries
- Experience working in a deadline driven environment prioritizing responsibilities
- Knowledge of Medicare/Medicaid regulations
- Experience with medical record review and identification of quality of care concerns
*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 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. #UHCPJ
