Secondary Review Team RN
About the position At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. As a Secondary Review Nurse, you will be conducting a review of long-term support services (LTSS) for the United Healthcare Community Plan of Idaho. This nurse will work with the service coordination teams to ensure that the LTSS services align with the state guidelines along with the policies and procedures of the health plan. Additionally, this nurse will track various reporting elements for analysis and trending along with serving as a resource to others. Hours are Monday - Friday 8am - 5pm. If you are located in the state of Idaho or neighboring states, you'll have the flexibility to work remotely as you take on some tough challenges.
Responsibilities
- Review technical metrics/specifications/ measures
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- Evaluate documentation of Functional Assessment, compare to adherence to form instructions
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- Review and compare to prior assessment for changes
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- Provide recommendations to SC completing assessment if areas of opportunity exist
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- Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC)
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- Review relevant HEDIS specifications to guide chart review
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- Review/ interpret/ summarize medical records/data to address quality of care questions
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- Review provider responses to reports/findings and correlate with medical records
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- Verify necessary documentation is included in medical records
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- Maintain HIPAA requirements for sharing minimum necessary information
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- Identify potential quality of care issues and potential fraud/waste/abuse based on review of clinical data/documentation
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- Solve moderately complex problems and/or conducts moderately complex analyses
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- Work with minimal guidance; seeks guidance on only the most complex tasks
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- Translate concepts into practice
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- Provide explanations and information to others on difficult issues
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- Coach, provides feedback, and guide others while acting as a resource for others with less experience
Requirements
- Current, unrestricted RN license in the state of Idaho
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- 6+ months of experience with Medicaid, Medicare, or Managed Care experience in long-term care, Long Term Services and Supports, home health, hospice, behavioral health, public health or assisted living
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- 6+ months of experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs
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- Intermediate level of computer / typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications
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- Intermediate knowledge of Idaho A&D Waiver benefits and service plan
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- Access to a designated quiet workspace in your home with the ability to secure Protected Health Information (PHI)
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- Reside in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
Nice-to-haves
- 6+ months of experience with completing State of Idaho Functional assessments and tools
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- Knowledge of community resources
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- Proven solid written and verbal communication skills
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- Proven problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
Benefits
- Comprehensive benefits package
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- Incentive and recognition programs
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- Equity stock purchase
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- 401k contribution
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