LPN Auditor

At UnitedHealth Group Inc., we're simplifying the healthcare 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 healthcare system of tomorrow, making it more responsive, affordable, and equitable.

This position will be responsible for gathering and auditing medical records from contacted medical providers. Analyze, track, and report results. Recommend, develop, educate, and implement quality improvement plans with providers and follow up as necessary.

• Review and audit Medicaid (AHCCCS) Electronic Visit Verification (EVV) providers and medical records regarding AHCCCS AMPM requirements around EVV.
• Review, audit, and evaluate documentation of medical records.
• Review/interpret medical records/data to determine whether there is documentation reflected accurately in medical records.
• Follow relevant regulatory guidelines, policies, and procedures in reviewing clinical documentation.
• Prioritize providers for medical chart review according to collaboration with other Health Plans.
• Identify incomplete/inconsistent information in medical records and label missing measures/metrics/concerns.
• Review relevant tool specifications to guide chart review.
• Review/interpret/summarize medical records/data to address any quality of care questions.
• Verify necessary documentation is included in medical records.
• Maintain HIPAA requirements for sharing minimum necessary information.
• Based on review of clinical data/documentation, identify potential quality of care issues (e.g., variations from standard practice potentially resulting in adverse outcomes) and potential fraud/waste/abuse.
• Refer issues identified to relevant parties (e.g., review committee, Case Management, Medical Directors) for further review/action.
• Discuss with provider offices to address and request corrective action plans.
• Educate provider representatives/office staff to address/improve auditing processes.
• Educate providers on proper medical record documentation for regulatory compliance.
• Educate providers offices on specifications/measures.
• Explain/convey technical specifications regarding action plans/follow up.
• Explain how provider scores are calculated/determined.
• Demonstrate knowledge of public healthcare insurance industry products (Medicaid).
• Demonstrate knowledge of Medicaid benefit products including applicable state regulations.
• Demonstrate knowledge of applicable area of specialization (e.g., community-based services).
• Demonstrate knowledge of computer functionality, navigation, and software applications (e.g., Windows, Microsoft Office applications, phone applications, fax server).
• Demonstrate 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 database).
• Prepare for and participate in meetings with State agencies, providers, and stakeholders as well as internal meetings.
• Assist with other quality management audits, corrective action plans as needed.
• This position will have on-site provider location visits throughout Arizona.
• This position is a work-from-home position with 50% in-state travel.

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 Inc. 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.