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Opportunities with ProHealth Physicians, part of the Optum family of businesses. When you work at ProHealth Physicians, your contributions directly sustain the health and well-being of our community. Discover high levels of teamwork, robust medical resources and a deep commitment to exceptional care and service. Join a leading community-based medical group and discover the meaning behind Caring. Connecting. Growing together.
The Clinical Quality Nurse performs clinical quality audits and reviews of prior authorization, inpatient acute and post-acute, complex case management, transitions of care, disease management, and medical claims review case work to evaluate compliance with department policies and regulatory requirements.
This role works closely with Case Management leadership to create and revise operational process documents that are used in evaluating case work on audit.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Evaluate medical management case work including Prior Authorization, Inpatient Acute and Post-Acute, Complex Case Management, Transitions of Care, and Clinical Claims to determine/verify whether medical necessity criteria were met using industry guidelines (CMS, Health Plan policies, MCG, InterQual, NCQA)
- Verify that time requirements for case work were met according to regulatory and departmental standards. (CMS, NCQA)
- Verify that service providers were in network, or that a gap in network coverage was present
- Follow relevant regulatory guidelines, policies, and procedures in reviewing clinical case documentation and medical necessity criteria selection (e.g., CMS, MCG, InterQual, NCQA)
- Follow relevant regulatory guidelines, policies, and procedures in reviewing complex case management, transitional case management, and disease management, to ensure care planning process meets regulatory and departmental requirements (NCQA)
- Verify if outreach for additional information was required and followed regulatory guidelines
- Verify that required communication to members and providers was completed as required by regulatory requirements and department policies
- Run/pull/prioritize relevant data/reports (e.g., case level data, audit trends, audit samples)
- Manipulate and leverage multiple databases (e.g., provider panels, medical review databases) to sort, search, and enter information
- Identify incomplete/inconsistent information in case reviews and document missing criteria/documentation/concerns
- Provide guidance to clinical staff to improve/standardize case review
- Identify and report quality of care concerns appropriately
- Report inconsistencies/problems with prior authorization, admissions, case management, transitions of care, and/or medical claims case review to appropriate parties for resolution.
- Maintain HIPAA requirements for sharing minimum necessary information
- Create and revise process documents in collaboration with process owners
Position Details:
- Schedule: Full time, 40 hours/weekly, Monday through Friday, 8:00AM – 4:30PM (Serving EST)
- Department: Clinical Quality & Audit
- Location: Telecommuter
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- Unrestricted current RN licensure in state of residence
- 1+ years of experience conducting medical necessity reviews utilizing established criteria such as CMS guidelines, MCG, InterQual, or NCQA standards
- 1+ years of experience managing complex cases, including care coordination, resource utilization, and multidisciplinary collaboration to achieve optimal outcomes
- Experience operating within multiple platforms that house case documentation and clinical records
- Proficiency in Microsoft Office using Word, Excel, and PowerPoint
- Proven excellent interpersonal and communication skills (both written and oral)
- Proven solid critical thinking and decision-making skills
- Proven ability to work on a multi-disciplinary team
Preferred Qualifications:
- Bachelor of Science, Nursing
- 3+ years of experience in managed care
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 – $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
