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.  

The Senior Clinical Quality RN will be responsible for conducting quality of care (QOC) and critical incident (CI) investigations, communicating findings from these reviews and preparing reports as needed to internal committees. Notifies external agencies of critical incident findings and uses state registry or other databases to document QOC and CI investigations.

Position in this function ensures that all quality of care and critical incident reporting complies 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.

If you are located Hawaii and have to ability to travel about 25% of the time, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

Positions in this function include RN (with current licensure) roles responsible for providing clinical expertise in any of the following areas:  

• Perform clinical documentation review of inpatient and outpatient care delivered to adults and children with Medicaid, Medicare health care benefits through Hawaii United Health Care Community Plans for peer review and internal investigations of Quality of Care concerns
• Create professionally written case investigation summaries for Peer Review, present case summaries at the Provider Advisory Committee as applicable
• Review plans of correction from providers in response to a substantiated QOC occurrence
• Effectively interface with external customers, facilities and providers to resolve quality of care concerns, obtain medical records and other information 
• Conduct delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare. This includes reviewing samples of contractor work against an audit tool or information found in medical charts
• Collaborate internally with Medical Directors and staff in other UHCCP departments
• Manage multiple tasks and projects and changing priorities; prioritize work products effectively
• Maintain timeliness for deliverables and regulator requests
• Work independently while utilizing good critical thinking skills, as well as excellent verbal and written communication skills
• Provide training, support and direction for new QOC RNs including development of training tools
• Develop and maintain collaborative relationships with assigned CCMAs
• Occasional on-site provider visits may be required for potential Quality of Care concerns

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Active, unrestricted RN license in the state of Hawaii
• 5+ years of experience working as a Registered Nurse
• 1+ years of hospital experience as a Registered Nurse
• Experience evaluating and auditing medical records
• Intermediate skills in Microsoft Office, Word, and Excel ability to work with multiple data bases to retrieve and enter information
• Resident of Hawaii
• Willing or ability to travel 25% of the time within the state of Hawaii, as needed 

Preferred Qualifications:

• Long-term care nursing experience
• Quality Management experience in a healthcare setting
• Experience analyzing information and preparing written summaries
• Experience working in a deadline driven environment prioritizing responsibilities
• Knowledge of Medicare/Medicaid regulations

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Hawaii Residents Only: The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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.

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