Network Quality RN - CPT, HCPCS Certified

This telecommuting position can be located near any UnitedHealth Group office in the continental US. This registered nurse reports to the Sr. Director of Network Quality and provides clinical quality expertise for the Network Quality team

• Works closely with Care Solutions Clinical Quality team
• Manages all QOC complaints including review, response, and reporting
• Engages physician review of QOC complaints
• Reviews current QOC filing process and evaluates alternate options for collection
• Develops and maintains close relationships with TDS, CMC and DM
• Reviews and summarizes QOC data
• Manages the SPR process
• Completes annual review of all existing QOC related documents and procedures
• Prepares quality reports for the Policy Committee
• Leads the department QIP program that demonstrates alignment, current quality trends and best practices
• Assists RN Clinical Analyst Team Lead and the RN Clinical Evidence Team Lead
• Supports Provider Performance Initiatives
• Evaluates, monitors, updates and improves the COE content on FOCUS
• Supports facility credentialing process in conjunction with CSI team
• Researches and summarizes current clinical evidence to identify key indicators for centers of excellence
• Documents clinical performance criteria and metrics to support provider performance programs
• Identifies clinical study strengths and weaknesses using Optum Hierarchy of Evidence
• Provides CPT guidance and clinical review of claims data for product development
  

• Current RN license required
• 3+ years of experience in clinical project management and analytics, quality audit review and claims analysis in a health care setting
• Advanced user of MS Office
• Certified in procedural (CPT and HCPCS) and diagnostic coding or willing to become certified within 3 months
• Documents at least 16 hours a year in QOC classes
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  OptumHealth is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
  
  
  
  OptumHealth helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their health care needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.
  
  
  
  At OptumHealth, you will perform within an innovative culture that's focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that's greater than you've ever imagined.
  
  
  
  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.