Field LPN/Licensed Practical Nurse Auditor, Clinical Quality Management - Phoenix, AZ

UnitedHealthcare
US - Arizona - Mesa
November 15, 2024

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.

This position will be responsible for the gathering and auditing of medical records from contacted medical providers.
Analyze, track, and report results.
Recommend, develop, educate and implement quality improvement plans with providers and follow up as necessary.

If you reside in Phoenix, AZ, you will enjoy the flexibility of a hybrid-remote role as you take on some tough challenges.
Must reside locally to Phoenix, AZ.

Primary Responsibilities:

Review and audit Medicaid (AHCCCS) Electronic Visit Verification (EVV) providers and medical records regarding AHCCCS AMPM requirements around EVV
Review, audit and evaluate documentation of medical records
Review/interpret medical records/data to determine whether there is documentation reflected accurately in medical record
Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation
Prioritize providers for medical chart review according to collaboration with other Health Plans
Identify incomplete/inconsistent information in medical records and label missing measures/metrics/concerns
Review relevant tool specifications to guide chart review
Review/interpret/summarize medical records/data to address any quality of care questions
Verify necessary documentation is included in medical records
Maintain HIPAA requirements for sharing minimum necessary information
Based on review of clinical data/documentation, identify potential quality of care issues (e.g., variations from standard practice potentially resulting in adverse outcomes) and potential fraud/waste/abuse
Refer issues identified to relevant parties (e.g., review committee, Case Management, Medical Directors) for further review/action
Discuss with provider offices to address and request corrective action plans
Educate provider representatives/office staff to address/improve auditing processes
Educate providers on proper medical record documentation for regulatory compliance
Educate providers offices on specifications/measures
Explain/convey technical specifications regarding action plans/follow up
Explain how provider scores are calculated/determined
Demonstrate knowledge of public healthcare insurance industry products(Medicaid
Demonstrate knowledge of Medicaid benefit products including applicable state regulations
Demonstrate knowledge of applicable area of specialization (e.g., community based services)
Demonstrate knowledge of computer functionality, navigation, and software applications (e.g., Windows, Microsoft Office applications, phone applications, fax server)
Demonstrate knowledge of specific software applications associated with the job function (e.g., navigation of relevant computer applications or systems, intranet databases, records management or claims database
Prepare for and participate in meetings with State agencies, providers, and stakeholders as well as internal meetings
Assist with other quality management audits, corrective action plans as needed
This position will have on site provider location visits throughout Arizona
This position is a work from home position with 50% in state travel

What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success.
Some of our offerings include:

Read the full job description and apply online on the recuiter's web-site

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