Clinical Quality RN - Telecommute - Pittsburg / Philadelphia, PA
January 9, 2018
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) If you are located in Philadelphia or Pittsburg, PA you will have the flexibility to telecommute* as you take on some tough challenges. Primary Responsibilities:Collaborate with appropriate department to document, investigate and resolve formal or informal member complaints and appeals in accordance with plan and state policies and procedures and requirements Review and analyze reports, records, and medical documents/charts Prepare reports and records on work function activities and projects Coordinate quality management and HEDIS related programs and activities as required Supports quality improvement programs requesting records from providers, maintaining databases, and researching to identify members' provider encounter history Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned Performs, provider and/or member outreach as required Participates in or coordinates with other department projects as neededThis is a telecommute position; must be within a commutable distance from either the Philadelphia, PA or Pittsburg, PA office. Some travel to job related meetings and activities is required.
Required Qualifications:Clinical RN with current licensure 5+ years clinical experience 2+ years of quality improvement experience Experience working in Medicaid and/or Medicare health care and insurance industry, including regulatory and compliance requirements Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry Experience with project coordination Strong organizational skills and ability to work both independently and with teams Ability to evaluate medical records with attention to detail Ability to interact with medical staff, peers, and internal company staff at all levels Ability to make formal presentations in front of committee and work group environments Ability to use databases and prepare reports as needed Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance and achieve targets Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from othersPreferred Qualifications:Bilingual Preferred experience with health plan Grievance and AppealsCareers 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. Job Keywords: RN, Quality, Quality improvement, Project management, project coordination, Appeals and Grievances, HEDIS, NCQA, Medicare, Medicaid, Telecommute, Telecommuter, Telecommuting, Remote, Pittsburg, Philadelphia, Pennsylvania, PA
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.