Sr. Clinical Quality RN - Albuquerque, NM - Full-time / Part-time

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)
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.
 
***This is NOT a telecommute position. You will be required to be in the Albuquerque office located at: 8220 San Pedro NE, Suite 300, Albuquerque, NM 87113***
 
Primary Responsibilities:

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

Required Qualifications:


Current unrestricted RN licensure in New Mexico.
1+ yrs of experience of Medicare/Medicaid regulations
2+ yrs of clinical experience as an RN
1+ yrs analytical and problem solving skills while managing multiple tasks simultaneously
Proficient in Microsoft Office, Word, and Excel 
 Preferred Qualifications: 


Knowledge of CMS Hospital Acquired Conditions and Never Events

Managed care experience or experience with a regulatory or accredited body     

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
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work(sm)
 
Diversity creates a healthier atmosphere: UnitedHealth Group 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.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
Job Keywords: Clinical Quality, RN, Registered Nurse, Albuquerque, NM, New Mexico