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UnitedHealth Group RN - Clinical Quality of Care - Phoenix, AZ in Phoenix, Arizona

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)

The Clinical Quality of Care RN will be responsible for conducting quality of care (QOC) investigation, review and management of the regulatory Incident/Accident/Death (AD) portal, documenting and communicating findings from these reviews, and preparing reports or summaries for internal and external customers. This position collaborates with the Chief Medical Officer or other Medical Directors to review QOC and other investigations, and ensures that QOC investigations comply with all applicable State, Federal, and regulatory requirements. These activities are used to ensure care and services supplied to our members are timely, adequate, and compliant with professional standards and guidelines.

This is an office-based position located at 1 East Washington Street in Phoenix.

Primary Responsibilities:

  • Perform clinical documentation review of inpatient and outpatient care delivered to adults, children with Medicaid, Medicare health care benefits through United Health Care Community Plans in Arizona for peer review and internal investigations of Quality of Care concerns

  • Apply behavioral health clinical knowledge and expertise to determine the degree to which an investigated occurrence increased the likelihood of adverse health outcomes, and determine if the actions taken by healthcare providers were consistent with current professional knowledge and guidelines

  • Create professionally written case summaries for Peer Review, and create written letters to regulatory agencies

  • Review plans of correction from providers in response to a substantiated QOC occurrence

  • Effectively interface with internal and external customers, facilities and providers to resolve quality of care concerns, obtain medical records and other information

  • Conduct delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare. This includes reviewing samples of contractor work against an audit tool or information found in medical charts

  • Perform on-site audits of residential care facilities such as assisted living facilities or practitioner offices

  • Collaborate with Medical Directors and staff in other UHCCP departments

  • Manage multiple tasks and projects and changing priorities; prioritize work products effectively

  • Maintain timeliness for deliverables and regulator requests

  • Must have the ability to work independently, good critical thinking skills, excellent verbal and written communication skills

Required Qualifications:

  • Active, unrestricted RN license in the state of Arizona

  • 5 + years of experience working as a Registered Nurse

  • 1 + years of hospital experience as a Registered Nurse

  • Experience evaluating and auditing medical records

  • Intermediate skills in Microsoft Office, Word, and Excel ability to work with multiple data bases to retrieve and enter information

Preferred Qualifications:

  • Knowledge of Medicare/Medicaid regulations

  • Quality Management experience in a healthcare setting

  • Experience analyzing information and preparing written summaries

  • Experience making public presentations

  • Experience working in a deadline driven environment prioritizing responsibilities

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)

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.

Keywords: Quality RN, Registered Nurse, RN, quality of care, QOC, CPC, clinical practice consultant, audit, Medicare, Medicaid, , healthcare, managed care, Phoenix, AZ, Arizona