UnitedHealth Group

Senior Clinical Quality RN Telecommute within San Antonio TX

Source: beBee S2

Careers at UnitedHealth Group
We're creating opportunities in every corner of the health care marketplace to improve lives while we're building careers. At UnitedHealth Group, we support you with the latest tools, advanced training and the combined strength of high caliber co-workers who share your passion, your energy and your commitment to quality. Join us and start doing your life's best work. SM Clinical
Compassion. It's the starting point for health care providers like you and it's what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you're also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life's best work. SM
Our teams are helping people from around the world. We can bring out your best as you put your listening, analytical and problem solving skills to work in a setting that is geared to helping improve lives and enhance health care for millions. Here, you'll discover a wealth of pathways for professional growth within Customer Service, Billing, Claims, Enrollment & Eligibility and across our global economy. Join us and find out why this is the place to do your life's best work. SM
There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)

The Senior Clinical Quality RN is responsible for monitoring and reporting compliance issues for the internal delegated functions of Medical Management requirements. This role works autonomously and meets stringent turnaround times. Will assist with quality monitoring to ensure Medical Management nurse performance is adherent to CMS and NCQA requirements, efficient, and effective in achieving performance goals. Monitoring includes ongoing internal performance audits with improvement actions and overall feedback on the process to ensure that delegation requirements pertaining to NCQA and CMS are met. Provides support to Medical Management staff members, collaborating to promote standard work processes, orchestrates collaboration of team efforts and works to ensure accountability for time and productivity to meet daily quota expectations. Position will be responsible for meeting both turnaround times and quota of case reviews.

If you reside within a commutable driving distance from San Antonio office , you will have the flexibility to telecommute* as you take on some tough challenges.
Primary Responsibilities:
  • Conducts review of Medical Management cases to ensure accuracy and compliance with CMS and NCQA requirements
  • Uses audit tools to perform documentation audits within Medical Management including, but not limited to:
    • Implements, tracks and analyzes audits on individual staff to monitor accuracy and integrity of compliance
    • Performs regular audits to ensure data entry accuracy
    • Performs regular audits to ensure compliance with required documentation
    • Identify and communicate with appropriate team members on audit results and/or deficiencies
    • Communicates regular audit results and trends to management and interfaces with managers, staff and training to make recommendations on potential training needs or revision in daily operations
  • Prepares and presents cases for audits
  • Uses internal system tracking tools for review of cases within established turnaround times
  • Reports on departmental functions to include, data entry accuracy and monthly trends of audits including, but not limited to:
    • Prepares monthly and/ or quarterly summary report compiling data
    • Prepares monthly and/ or quarterly detailed and trending employee report
  • Participates in the development, planning, and execution of auditing processes
    • Foster open communication with managers/directors
    • Identify and communicate with appropriate departments, teams, and key leadership on audit results and/or deficiencies
    • Identify and communicate findings of case audits compliance with CMS and NCQA requirements to individuals audited and key leadership
  • Manages and performs tasks related to audits from contracted health plans as well as pre-delegation review with potential health plans
    • Participates in delegation audits and assists business with supplying information as needed
  • Notifies appropriate personnel to make any needed corrections in errors
    • Prepares reports including those that require manual entry
    • Validates accuracy of reports prior to submission.
    • Submits reports timely according to health plan requirements
  • Updates resource training materials and work plans within assigned responsibilities
  • Provides feedback and education to staff
  • Performs all other related duties as assigned
  • Proven ability to accurately complete medication reconciliation

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 Texas RN license or compact license with the ability to obtain additional licenses as directed
  • Minimum of Associates degree in Nursing, or nursing diploma with 4 additional years of experience beyond the required years of experience may be substituted in lieu of a degree
  • Three (3) or more years of experience in managed care, with previous auditing experience
  • Training and presentation- skills with solid communication capabilities and practices, both oral and written
  • Proficiency with Microsoft Office applications, including but not limited to databases, word-processing, spreadsheets, and graphical displays
  • Must reside within a commutable driving distance from San Antonio office
  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.

Preferred Qualifications:
  • Knowledge and experience with CMS, URAC and/or NCQA required
  • Proven ability to accurately complete medication reconciliation and care plans
  • Health Plan or MSO quality, audit or compliance experience
  • Undergraduate degree
  • Bilingual (English/Spanish) language proficiency
  • Strong knowledge of all Medical Management and Model of Care compliance requirements
  • Previous auditing, training or leadership experience
  • Strong teamwork, interpersonal, verbal, written, and administrative and customer service skills
  • Proven capability to work with people at all levels in an organization
  • Clinical data abstraction experience
  • Adaptable to change
  • Strong writing, proofreading and grammar skills
  • Good business acumen, especially as it relates to Medicare and Medicaid

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

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

Job Keywords: RN, Case Manager RN, URAC, NCQA, Case Manager, Audit, San Antonio, New Braunfels TX, Seguin TX
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918763


2 days ago



San antonio, Tx

UnitedHealth Group

Full Time

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