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) Ensuring that the Adverse Letters 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. **This position requires rotational Saturdays.** Primary Responsibilities: Coordinates internal reviews on denial letters to determine compliance with contractual and regulatory requirements of the State and Federal 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
Fully bilingual (Spanish) - reading, writing, speaking
Proven analytical and problem solving skills while managing multiple tasks simultaneously
Ability to work independently or in a team environment
Demonstrated excellent written and verbal communication skills
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
Knowledge of State and Federal Regulations
Excellent computer skills with direct experience in Microsoft Office, Word and Excel
Managed care experience or experience with a regulatory or accredited body
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 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: 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: Bilingual, RN, Quality reviewer, benefits, contracts, telecommute, telecommuting, telecommuter, work from home, remote