Clinical Quality Auditor, RN

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Positions in this function are responsible for direction and guidance on clinical quality improvement and management programs including accreditation. Conducts clinical quality audits and may also be responsible for NCQA requirements. Responsible for the reporting and analysis of member care quality and for the development of plans and programs to support continuous quality improvement.

You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Review and audit contracted sub-delegates
• Assist with report preparation and records regarding work function activities and projects
• Supports Medical Management Initiatives with quality improvement. Included but not limited to these departments: case management, utilization management programs and Medical Director Initiatives)
• Participates in and represents the Clinical Quality Team by collaborating with internal business partners focusing on quality improvement
• Participates in or coordinates with other departmental projects as needed
• Education to staff or contracted entities as needed
• Performs other duties as assigned

Professional Competencies:

• Working knowledge of health care delivery systems
• Working knowledge of PC applications including MS Office Suite. Ability to use written and oral communication skills
• Ability to read and interpret data
• Skill in writing clear, grammatically correct
• Easy to use instructional documentation
• Ability to identify learning needs, set goals and seek educational opportunities
• Ability to analyze problems and formulate appropriate plans, solutions, and courses of action
• Knowledge of age specific communication needs with the ability to listen actively and respond to internal and external customers in a timely, competent manner both verbally and nonverbally
• Ability to work with frequent interruptions
• Ability to establish and maintain cooperative working relationships with individuals at all levels of the organization and affiliates
• Ability to maintain confidentiality of patient and all related entity business matters of the organization and its partners
• Ability to manage detail and work with accuracy
• Ability to recognize and act appropriately in situations where patient care needs exceed scope of practice
• Skill in working with a team and the ability to collaborate on projects with colleagues
• Skill in working effectively under deadlines and changing priorities

Skills:

• All staff members are to promote a positive and productive work environment by acting maturely and responsibly, satisfactorily performing his or her job responsibilities and conducting themselves in a professional, courteous and respectful manner toward fellow employees, physicians and patients
• Must hold relationships to a high standard- respectful approach to all people and interactions, listening to understand, take emotional accountability and exemplify balance of self with all interactions, be receptive to feedback and opportunities keeping an open mind towards growth
• Integrates Lean principles, practices and tools to improve operational efficiency, reduce costs and increase customer satisfaction
• Follows written and oral instructions and completes routine tasks independently
• Completes annual compliance training on HIPAA/Privacy/Confidentiality/Non-Discrimination/Harassment/Integrity Statement and signed Agreements
• Ensures confidentiality of patient information following HIPAA guidelines and company policies
• Attends training to meet requirements of the job position and as needed or mandated by company policies and regulations
• Has regular and predictable attendance

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:

• Current unrestricted RN license
• 5+ years of clinical experience
• 1+ years of clinical quality experience
• 1+ years working in managed care or in the insurance industry
• Experience with Medicare and/or Medicaid
• Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements
• Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Teams and Outlook
• Proven ability to evaluate medical records with attention to detail to perform quality audits
• Proven solid organizational skills, self-motivated and ability to interact with company staff at all levels
• Access to a safe quiet space to work as a telecommuter

Preferred Qualifications:

• Subject matter expert for CMS
• Experience with project coordination
• Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance and achieve targets
• Demonstrated ability to do formal presentations in different settings- internal/external auditors, reporting on projects and reports that have been created and analyzed

• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

The salary range for this role is $59,500 to $116,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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...

OptumCare 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.