Secondary Review Team RN
About the position Responsibilities • Review technical metrics/specifications/ measures • Evaluate documentation of Functional Assessment, compare to adherence to form instructions • Review and compare to prior assessment for changes • Provide recommendations to SC completing assessment if areas of opportunity exist • Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC) • Review relevant HEDIS specifications to guide chart review • Review/ interpret/ summarize medical records/data to address quality of care questions • Review provider responses to reports/findings and correlate with medical records • Verify necessary documentation is included in medical records • Maintain HIPAA requirements for sharing minimum necessary information • Identify potential quality of care issues and potential fraud/waste/abuse based on review of clinical data/documentation • Solve moderately complex problems and/or conducts moderately complex analyses • Work with minimal guidance; seeks guidance on only the most complex tasks • Translate concepts into practice • Provide explanations and information to others on difficult issues • 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 • 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 • 6+ months of experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs • 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 • Intermediate knowledge of Idaho A&D Waiver benefits and service plan • Access to a designated quiet workspace in your home with the ability to secure Protected Health Information (PHI) • 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 • Knowledge of community resources • Proven solid written and verbal communication skills • Proven problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action Benefits • Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution Apply tot his job Apply To this Job