Clinical Quality RN

2 weeks ago

San Antonio, Texas, United States UnitedHealth Group Inc Full time
Job Title: Clinical Quality RN

We are seeking a highly skilled Clinical Quality RN to join our team in San Antonio, TX. As a Clinical Quality RN, you will be responsible for monitoring and reporting compliance issues, as well as overseeing Utilization Management (UM) organization determinations.

Key Responsibilities:
  • Conducts audit reviews of Organization Determinations, Adverse Determinations, and Notice of Medicare Non-Coverage documents to ensure accuracy and compliance with UM health plan, CMS, NCQA, URAC, and Department of Insurance guidelines.
  • Utilizes audit tools to perform documentation audits on job functions within Utilization Management.
  • Performs regular audits to ensure data entry accuracy and compliance of required documentation.
  • Communicates regular audit results to management and interfaces with managers, staff, and training to make recommendations on potential training needs or revision in daily operations.
  • Reports on departmental functions, including data entry accuracy and monthly trends of internal audits.
  • Prepares monthly and/or quarterly summary reports compiling data for all markets.
  • Prepares monthly and/or quarterly detailed and trending employee reports.
  • Participates in the development, planning, and execution of auditing processes.
  • Fosters open communication with managers/directors by acting as a liaison between the Training Department(s), the Medical Management Department(s), and the Utilization Departments.
  • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies.
  • Identifies and communicates gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership.
  • Recognize when additional regulations may apply, research, and collect additional data as needed to obtain relevant information.
  • Analyzes results, provides interpretation, and identifies areas for improvement.
  • Provides internal and external results compared with goals for annual program evaluations and presentation to the Medical Management and Utilization Management, and Clinical Education Departments.
Requirements:
  • Bachelor of Science in Nursing (Associate Degree or Nursing Diploma from accredited nursing school with 2 or more years of additional experience may be substituted in lieu of a bachelor's degree).
  • Current unrestricted Registered Nurse (RN) with current license in Texas, or other participating States.
  • 5+ years of progressively responsible healthcare experience to include experience in a managed care setting, and/or hospital settings, and/or physician practice setting.
  • 3+ years of experience in managed care with at least 2+ years of Utilization Management experience.
  • Knowledge and experience with CMS, URAC, and NCQA.
  • Knowledge of Medicare and Medicaid benefit products including applicable state regulations.
  • Knowledge of computer functionality navigation and proficiency with Microsoft Office applications required (e.g., Windows, Microsoft Office applications including Microsoft Word and Microsoft Excel).
  • 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).
  • Willing to occasionally travel in and/or out-of-town as deemed necessary.
Preferred Qualifications:
  • Health Plan or MSO quality, audit, or compliance experience.
  • Auditing, training, or leadership experience.
  • Solid knowledge of Medicare and TDI regulatory standards.
  • Solid knowledge of process flow of UM including prior authorization and/or clinical appeals and grievance reviews.
Physical & Mental Requirements:
  • Ability to push or pull heavy objects.
  • Ability to properly drive and operate a company vehicle.
Values Based Competencies Employee:
  • Integrity Value: Act Ethically.
  • Comply with Applicable Laws, Regulations, and Policies.
  • Demonstrate Integrity.
  • Compassion Value: Focus on Customers.
  • Identify and Exceed Customer Expectations.
  • Improve the Customer Experience.
  • Relationships Value: Act as a Team Player.
  • Collaborate with Others.
  • Demonstrate Diversity Awareness.
  • Learn and Develop.
  • Relationships Value: Communicate Effectively.
  • Influence Others.
  • Listen Actively.
  • Speak and Write Clearly.
  • 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.
  • Performance Value: Deliver Quality Results.
  • Drive for Results.
  • Manage Time Effectively.
  • Produce High-Quality Work.

We are an equal opportunity 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.

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