There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm) 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. Primary Responsibilities: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 responsibilitiesThis position is located on-site at our Bishop Street office in Honolulu.
Required Qualifications: Current unrestricted RN licensure in HI 2+ years of clinical RN experience Proficiency using a PC in a Windows environment, including MS Word Proven analytical and problem solving skills while managing multiple tasks simultaneously Preferred Qualifications: BSN Knowledge of CMS Hospital Acquired Conditions and Never Events Knowledge of Medicare / Medicaid regulations Managed care experience or experience with a regulatory or accredited body strongly preferred 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 Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 17 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm) Diversity creates a healthier atmosphere: 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. In addition, employees in certain positions are subject to random drug testing. Job Keywords: RN, Registered Nurse, Clinical Quality Nurse, Clinical Quality RN, Charge Nurse, Analyst, Health Care, Medicaid, Medicare, HEDIS, NCQA, Managed Care, Clinical, Clinical Practice Consultant, Honolulu, HI, Hawaii
Internal Number: 741537
About UnitedHealth Group
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.