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.
The Clinical Quality RN will be responsible for conducting quality of care (QOC) and critical incident (CI) investigations, communicating findings from these reviews and preparing reports as needed to internal committees. Notifies external agencies of critical incident findings and uses state registry or other databases to document QOC and CI investigations.
Ensuring that all quality of care and critical incident reporting complies with all applicable State and Federal laws and consent decrees, as well as the applicable accrediting regulatory review agencies, including but not limited to CMS, NCQA, HIPAA, and all UHC policies and procedures as applicable.
If you are located on Oahu, HI, you will have the flexibility to work remotely* as you take on some tough challenges. Travel is required on Oahu about 25% of the time.
Primary Responsibilities:
Positions in this function include RN (with current licensure) roles responsible for providing clinical expertise in any of the following areas: Coordinates reviews of reported QOC and CI occurrences Defines and documents potential level of care for QOC and CI Takes actions to report CI according to State and Federal guidelines and UHG policy and procedure Takes actions to investigate QOC or CI, requests medical records or other detail files from external organizations in order to complete QOC or CI review Completes required reports of QOC and CI activities based on internal and external reporting timetables Prepares summary information about QOC or CI and effectively presents this information to internal committees or other review experts Performs internal Quality Control reviews on processes and activities while developing recommendations for improvement Serves as a catalyst for implementing an appropriate risk assessment process designed to identify and correct deficiencies or poor trends in care Assists with the coordination of external audits and reviews conducted by our clients or contracting organizations Maintain extensive knowledge of regulatory and applicable accrediting body requirements becoming a Compliance resource for the team Proficient in interpreting benefits, contracts, and medical policy Review denial notice issued by the National Letter team to ensure accuracy and compliance, as well as providing recommendations for improvement, as needed Maintain knowledge of State rules, contracts, and Federal legislation/regulations as well as UHG guidelines Establish and maintain good working relationships throughout the company to support goals and objectives Demonstrate flexibility, availability, and dependability to conform to position responsibilities
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 HI 2+ years of clinical RN experience Proficiency using a PC in a Windows environment, including MS Word Willing or ability to travel about 25% of the time on Oahu Must reside in Hawaii
Preferred Qualifications:
BSN Managed care experience or experience with a regulatory or accredited body Knowledge of CMS Hospital Acquired Conditions and Never Events Knowledge of Medicare / Medicaid regulations Ability to work independently or in a team environment High attention to detail, exceptional documentation abilities, and organizational skills Proven ability to meet critical deadlines consistently, while completing tasks accurately Proven analytical and problem-solving skills while managing multiple tasks simultaneously
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
The salary range for this role is $59,500 to $116,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with al minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
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.
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.