Remote Clinical Quality Care RN, Advantage Plus Network of CT

Opportunities with Advantage Plus Network - Connecticut, part of the Optum family of businesses. When you work at Advantage Plus Network - Connecticut, 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.

Position Overview:
The Clinical Quality Nurse performs clinical quality audits and peer reviews of prior authorization, complex case management, transitions of care, disease management, and medical claims review case work to evaluate compliance with department policies and regulatory requirements.

Position Details:

• Schedule: Full time, 40 hours/weekly, Monday through Friday, 8:00AM - 4:30PM.
• Department: Clinical Quality & Audit
• Location: Telecommuter, however this position is aligned with the east coast time zone

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, 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 review documentation and medical necessity criteria selection (e.g., CMS, NCQA, HEDIS)
• 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 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)
• Prioritize services for medical chart review (e.g., high volume or high-cost services)
• 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.
• Direct activities/target learning to increase case review quality scores and improve case review processes
• Maintain HIPAA requirements for sharing minimum necessary information

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
• 2+ years of experience in clinical case review or chart auditing using CMS, MCG, NCQA criteria
• 2+ years of experience of medical management while working in a remote setting
• Experience operating within multiple platforms that house case documentation and clinical records
• Proficient in Microsoft Office
• Proven excellent interpersonal and communication skills (both written and oral)
• Proven ability to work on a multi-disciplinary team

Preferred Qualifications:

• Bachelor of Science, Nursing
• 5+ years of experience in medical management
• EMR experience (EPIC)

Connecticut Residents Only: The salary range for this role is $58,300 to $114,300 annually. 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.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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