Evaluate documentation of medical care Review / interpret medical records / data to determine whether there is documentation that medical services were rendered Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC) Run / pull / prioritize relevant data / reports (e.g., member level data, geographical trends, provider data) Manipulate and leverage multiple databases / Electronic Medical Records applicati... more details
At UnitedHealthcare, were 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.
This position works under the supervision of the CQM Studies Manager Manager of Clinical Delegation. Develops and conducts clinical audits, quality studies (CQS), clinical quality improvement initiatives, (QIIs), Clinical quality process improvement activities/initiatives, (QIAs) and retrospective focused reviews, and monitors / evaluates outcomes of corrective action plans
Youll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Evaluate documentation of medical care
- Review / interpret medical records / data to determine whether there is documentation that medical services were rendered
- Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC)
- Run / pull / prioritize relevant data / reports (e.g., member level data, geographical trends, provider data)
- Manipulate and leverage multiple databases / Electronic Medical Records applications(e.g., provider panels, medical review databases) to sort, search, and enter information
- Review relevant HEDIS specifications to guide chart review
- Review / interpret / summarize medical records / data to address quality of care questions
- Review medical records for compliance with regulatory guidelines (e.g., NCQA, state Medicaid contracts, Clinical Practice Guidelines)
- Utilizes evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
- Identifies and implements innovative approaches to the practice, in order to achieve or enhance quality outcomes and financial performance
- Generate reports / findings of reviews
- 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
Youll 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:
- Bachelors Degree
- Unrestricted RN license in the state of Ohio
- 5+ years of RN experience
- 5+ years clinical experience
- 2+ years Care Management experience
- 2+ years of Managed Care
- Auditing experience
- Comprehensive knowledge of research methodology, HEDIS measures, benchmarking
- Intermediate computer skills with emphasis on Microsoft Office software (Windows, Word, and Excel) and databases
Preferred Qualifications:
- Masters degree
- 1+ years experience conducting research or studies
- Quality Management experience
- Demonstrated formal writing experience
- Knowledge of process and procedure improvement
*All employees working remotely will be required to adhere to UnitedHealth Groups Telecommuter Policy
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington or Washington, D.C. Residents Only: The salary range for this role is $58,300 to $114,300 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all 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, youll find a far-reaching choice of benefits and incentives.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyoneof every race, gender, sexuality, age, location and incomedeserves 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.
