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