Status: Full-time position
Location: Albuquerque, NM
Deadline Date:
Date Available:
Job Summary: The Sr. 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.
Qualifications: Requires current unrestricted RN licensure in applicable state.
Undergraduate degree or equivalent experience
Knowledge of Medicare/Medicaid regulations required
Proficient computer skills with direct experience in Microsoft Office, Word, PowerPoint, and Excel required
Demonstrated excellent written and verbal communication skills required.
Proven analytical and problem solving skills while managing multiple tasks simultaneously
Additional Assets
Knowledge of CMS Hospital Acquired Conditions and Never Events
Managed care experience or experience with a regulatory or accredited body strongly preferred
Ability to work independently or in a team environment
The applicant should possess a high attention to detail, exceptional documentation abilities, and organizational skills
Proven ability to meet critical deadlines consistently, while completing tasks accurately.
Proven ability to handle multiple tasks simultaneously by working independently, as well as part of a team, in a fast paced environment.
UnitedHealthcare Employer & Individual works with individuals, small businesses and large multi-site employers to provide innovative, affordable benefits services.UnitedHealthcare Medicare & Retirement is focused on serving Americans over the age of 50. It is the largest business dedicated to meeting the growing health and well-being needs of aging individuals in the nation, serving one in five Medicare beneficiaries through a comprehensive and diversified array of products and services through four industry-leading businesses.UnitedHealthcare Community & State provides high-quality, personalized, public-sector health care programs that help local government agencies improve health outcomes for millions of children and low-income and disabled individuals at an affordable cost.Together, we're removing the barriers that keep people from receiving the kind of quality health care that makes a difference. We focus on Integrity, Compassion, Relationships, Innovation and Performance as we empower people to achieve better health and well-being.Come grow and thrive in our culture of innovation and ideas. Because there is no opportunity greater than the quest to help people live healthier lives.
Duties: 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 responsibilities.
To Apply:
To apply online, visit
http://www.newmexicodiversity.com/j/t-Senior-Clinical-Quality-RN-Albuquerque-New-Mexico-Office-e-UnitedHealth-Group-l-Albuquerque,-NM-jobs-j3189880.html