Description |
UnitedHealthcare has an excellent opportunity available for a licensed RN in Brentwood or Knoxville, TN. The
Senior Clinical Admin Nurse is responsible for independent checks for validity, accuracy, and completeness of cases, ensuring that the notification coordinators comply 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.
Responsibilities:
- Coordinates internal reviews on denial letters to determine compliance with contractual and regulatory requirements of the State Medicaid programs, while reviewing for efficiencies and effectiveness of procedures
- 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
- 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
- Interact effectively with other departments.
- 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.
The position may be eligible for telecommuting after six months in the department.
Key Words: clinical, audit, compliance, compliant, appeal, CMS, NCQA, HIPAA, URAC, guidelines, medicaid, medicare, registered nurse, rn, regulation, regulatory, state, fed, federal, risk, quality, quality control
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Requirements |
QUALIFICATIONS:
- Unrestricted RN License required in the State of residence
- 3 years clinical nursing background
- Familiarity with NCQA, Medicaid and Medicare guidelines
- Strong ability to use a PC in a Windows environment
- Proven analytical and problem solving skills while managing multiple tasks simultaneously
- Demonstrated excellent written and verbal communication skills required.
- 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.
Desired Assets:
- Bilingual in Spanish and English highly desired
- Medical record review/appeal review experience preferred
- Case Management and Utilization Review experience preferred
- Nurse Auditing experience using Milliman Criteria preferred
- Managed care experience and/or experience with a regulatory or accredited body strongly preferred
UnitedHealthcare, part of the
UnitedHealth Group family of companies, is comprised of three specialized businesses dedicated to meeting the health care benefits needs of individuals and groups; all part of something greater, but each with a specialized focus:
UnitedHealthcare Employer & Individual works with individuals, small businesses and large multi-site employers to provide innovative, affordable benefits services.
UnitedHealthcare Medicare & Retirement is focused on serving Americans over the age of 50. It is the largest business dedicated to meeting the growing health and well-being needs of aging individuals in the nation, serving one in five Medicare beneficiaries through a comprehensive and diversified array of products and services through four industry-leading businesses.
UnitedHealthcare Community & State provides high-quality, personalized, public-sector health care programs that help local government agencies improve health outcomes for millions of children and low-income and disabled individuals at an affordable cost.
Together, we're removing the barriers that keep people from receiving the kind of quality health care that makes a difference. We focus on Integrity, Compassion, Relationships, Innovation and Performance as we empower people to achieve better health and well-being.
Come grow and thrive in our culture of innovation and ideas. Because there is no opportunity greater than the quest to help people live healthier lives.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
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.
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