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Hours Full-time, Part-time
Location Honolulu, HI
Honolulu, Hawaii

About this job


The 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.

Primary Functions


 


Positions in this function include RN (with current licensure) roles responsible for providing clinical expertise in any of the following areas:



  • 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

Requirements

Requirements:


 




  • Current unrestricted RN licensure in HI.

  • A minimum of 2 years of clinical RN experience

  • Knowledge of Medicare/Medicaid regulations

  • Proficient in Microsoft Office, Word, and Excel

  • Demonstrated excellent written and verbal communication skills

  • Proven analytical and problem solving skills while managing multiple tasks simultaneously



Additional Assets



  • BSN

  • 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.

  • MS Powerpoint


Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 17 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.SM

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.


 


Keywords: RN, Registered Nurse, Quality, HEDIS, NCQA, Medicare, Medicaid