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    Sr Clinical Quality Rn – Remote On Oahu, Hi

    Optum
    5+ years
    Not Disclosed
    Honolulu
    10 Nov. 20, 2024
    Job Description
    Job Type: Full Time Remote Education: B.Sc./ M.Sc./ M.Pharm/ B.Pharm/ Life Sciences Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

    Job Title: Senior Clinical Quality RN – Remote (Hawaii)

    Job Summary

    At UnitedHealthcare, we are committed to simplifying the health care experience, creating healthier communities, and removing barriers to quality care. Join us in building the health care system of tomorrow – one that is more responsive, affordable, and equitable. The Senior Clinical Quality RN plays a critical role in conducting quality of care (QOC) and critical incident (CI) investigations. You will be responsible for reviewing clinical documentation, preparing case summaries, and reporting findings to internal committees and external agencies as needed. This position ensures compliance with state and federal laws, including CMS, NCQA, HIPAA, and UnitedHealthcare policies.

    If you are a Hawaii resident with the ability to travel within the state, this role offers the flexibility to work remotely while contributing to meaningful work that impacts lives.

    Primary Responsibilities:

    • Conduct clinical documentation reviews for inpatient and outpatient care for Medicaid and Medicare beneficiaries within the Hawaii UnitedHealthcare Community Plans.
    • Prepare detailed case investigation summaries and present findings at Peer Review and Provider Advisory Committee meetings.
    • Review and evaluate plans of correction from providers related to substantiated QOC incidents.
    • Collaborate with external customers, facilities, and providers to resolve QOC concerns and obtain medical records.
    • Perform delegated oversight reviews of contractors conducting work on behalf of UnitedHealthcare.
    • Collaborate with Medical Directors and internal teams to resolve quality issues and manage multiple tasks effectively.
    • Maintain timely deliverables and comply with regulatory requests.
    • Train and support new QOC RNs, including creating training tools and providing direction.
    • Build and maintain collaborative relationships with CCMAs and assist with potential QOC concerns through on-site provider visits as needed.

    Required Qualifications:

    • Active, unrestricted RN license in Hawaii.
    • 5+ years of experience as a Registered Nurse.
    • 1+ year of hospital-based nursing experience.
    • Experience in evaluating and auditing medical records.
    • Proficiency with Microsoft Office, Excel, Word, and working with multiple data bases.
    • Resident of Hawaii with the ability to travel 25% within the state.

    Preferred Qualifications:

    • Long-term care nursing experience.
    • Experience in Quality Management within a healthcare setting.
    • Knowledge of Medicare/Medicaid regulations.
    • Ability to prepare written summaries and meet deadlines in a fast-paced environment.

    Compensation & Benefits:

    • Salary range: $70,200 – $137,800 annually (based on experience and qualifications).
    • Comprehensive benefits package, including health, dental, vision, and life insurance.
    • 401(k) with company match, equity stock purchase, and incentive programs.
    • Paid time off, including vacation, sick leave, and holidays.
    • Benefits begin on Day 1 and are subject to eligibility requirements.

    Join Us in Making a Difference:

    At UnitedHealth Group, we are committed to delivering equitable care and improving health outcomes for all communities. Diversity is at the heart of our mission, and we are an Equal Employment Opportunity/Affirmative Action employer. We strive to create a workforce that reflects the diverse backgrounds, perspectives, and experiences of the people we serve.

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