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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 in Honolulu, HI, you will have the flexibility to telecommute* as you take on some tough challenges. Travel to local Honolulu office required based on business needs.
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.
Current unrestricted RN licensure in HI
2+ years of clinical RN experience
Proficiency using a PC in a Windows environment, including MS Word
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
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place 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.