Clinical Quality RN – Remote

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This position is for a registered nurse who monitors various processes and supports regulatory compliance via quality auditing. The Optum West Clinical Quality RN functions as a quality auditor who completes various audits of internal clinical and non-clinical documentation based on delegation and regulatory requirements. This role may support the provision of education and training related to audit findings and trends.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Must have active RN license in state of residence and must be willing to work 8-5PM Pacific Standard Time (PST)

Primary Responsibilities:

• Uses pertinent data and facts to complete quality audits to identify errors or missing information in clinical documentation for utilization management (UM) and care management (CM) functions
• Investigates quality audit performance findings and/or problems, with some assistance from others
• Works within a specific knowledge area – to include UM/CM regulatory and delegation requirements as outlined in internal resources
• Prioritizes and organizes own work to meet deadlines
• Provides explanations and information to others on topics within area of expertise as needed
• Participates in inter-rater reliability exercises to promote audit consistency
• Assist with report preparation and records regarding work function activities and projects
• Supports Medical Management Initiatives with quality improvement. Included but not limited to these departments: case management, utilization management programs and Medical Director Initiatives)
• Collaborates with internal business partners focusing on quality improvement
• Education to staff or contracted entities as needed
• Performs other duties as assigned

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:

• Undergraduate Degree or equivalent 
• Current, unrestricted RN license or temporary license with the ability to obtain permanent RN license upon expiration of temporary RN license.
• 5+ years of clinical experience
• 1+ years of working in managed care or in the insurance industry
• Experience with Medicare and/or Medicaid
• Proven ability to evaluate medical records with attention to detail to perform quality audits

Preferred Qualifications:

• 1+ years of clinical quality experience
• Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements
• Proven solid organizational skills, self-motivated and ability to interact with company staff at all levels

Skills:

• All staff members are to promote a positive and productive work environment by acting maturely and responsibly, satisfactorily performing his or her job responsibilities and conducting themselves in a professional, courteous and respectful manner toward fellow employees, physicians and patients
• Must hold relationships to a high standard- respectful approach to all people and interactions, listening to understand, take emotional accountability and exemplify balance of self with all interactions, be receptive to feedback and opportunities keeping an open mind towards growth
• Integrates Lean principles, practices and tools to improve operational efficiency, reduce costs and increase customer satisfaction
• Follows written and oral instructions and completes routine tasks independently
• Completes annual compliance training on HIPAA/Privacy/Confidentiality/Non-Discrimination/Harassment/Integrity Statement and signed Agreements
• Ensures confidentiality of patient information following HIPAA guidelines and company policies
• Attends training to meet requirements of the job position and as needed or mandated by company policies and regulations
• Has regular and predictable attendance

Professional Competencies:

• Working knowledge of health care delivery systems
• Working knowledge of PC applications including MS Office Suite
• Ability to use written and oral communication skills
• Ability to read and interpret data
• Skill in writing clear, grammatically correct, easy to use instructional documentation
• Ability to identify learning needs, set goals and seek educational opportunities
• Ability to analyze problems and formulate appropriate plans, solutions, and courses of action
• Knowledge of age specific communication needs with the ability to listen actively and respond to internal and external customers in a timely, competent manner both verbally and nonverbally
• Ability to work with frequent interruptions
• Ability to establish and maintain cooperative working relationships with individuals at all levels of the organization and affiliates
• Ability to maintain confidentiality of patient and all related entity business matters of the organization and its partners
• Ability to manage detail and work with accuracy
• Ability to recognize and act appropriately in situations where patient care needs exceed scope of practice
• Skill in working with a team and the ability to collaborate on projects with colleagues
• Skill in working effectively under deadlines and changing priorities

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.