Landmark Health, part of the Optum and UnitedHealth Group family of businesses, was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are ill-equipped to navigate our overwhelming healthcare system.
The Senior Quality Nurse Auditor is responsible, as part of the Landmark Health Quality Compliance team, for completing audits associated with CCM (Complex Case Management), Quality Assurance, Regulatory Compliance, Documentation, Medical Quality, OSHA, validation, outcomes, process and performance. Completes independent assessments of patient charts in accordance with policies and procedures, clinical guidelines, applicable regulatory standards and client requirements. Works closely with their assigned Market Leadership to assist with training needs and improvement activities identified through the audit and corrective action process to ensure the Market is in the position to meet all requirements internal and external. Assist with the training of new NCMs and provide feedback to the Market Leadership team with regards to progress and support the team with maintaining current knowledge across all team members with regards to updates to the expectations, regulations or processes.
Uses assessment and evaluation skills to conduct delegation, regulatory and performance audits and manages the corrective/improvement process to ensure compliance. Working in collaboration with the Market and Department leadership to identify opportunities, develop corrective actions, provide education, provide monitoring to ensure success. Solid CM knowledge and experience is necessary.
You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
- Conduct Complex Care Management chart audits within OnSpring
- Provide real time feedback as to open issues with records to meet compliance
- Provide orientation/training to new NCMs to set a solid foundation
- Work closely with assigned Market Leadership to assess ongoing training needs through regular communication
- Conduct the data collection for regulatory audits such as:
- Notice of Privacy Practices, Release of Medical Records, Authorized Representative (list is not all inclusive)
- Conduct the data collection for performance and outcomes audits, such as:
- Medical Records Audits, Guideline Compliance, Outcomes Management audits, Data Integrity and Outcomes Audits (list is not all inclusive)
- Data collection for Quality Improvement activities and monitoring performance
- Track all CCM referrals including key indicators vs. timeline (i.e., HFA, HSA and care plans quality)
- Conduct CCM delegation training for new hires and ongoing training based on audit results and team member needs
- Independently use discretion and judgment to evaluate objective and subjective clinical documentation to assess performance of nursing skill and the skills of other allied health professionals, based on Regulatory Standards, Health Plan and contractual obligations, and company policy
- Applies advanced knowledge to conduct multi-specialty subjective assessments to evaluate the skills of nurses and other allied health professionals
- Consults with the assigned Market Leadership to collaborate on subjective assessments to ensure consistency of feedback related to complex, high-risk cases
- Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow policies, State regulations and Accreditation standards
- Collate all data available to illustrate a full picture of Company, Market and individual staff members performance
- Generate reports /findings of reviews: in a clear, concise manner that is understandable and actionable
- Provide consultation to support staff coaching and development efforts
- Assist, as needed, to determine areas that require immediate remediation and assist employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and member engagement
- Identifies tracks and records best practices, sharing the specifics with Market leadership
- Participate in and conduct training and performance improvement related projects to support staff development as well as assist with the training of new employees
- The Clinical Nurse Auditor will highlight key findings for implementation of performance improvement plans when necessary
- Participate in NCQA accreditation activities
- Work with colleagues across Market units to ensure that process and procedural changes are reflected in staff member documentation such as job aids and policies
- Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served
- Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner
- Ability to work and interact with professionals as part of an interdisciplinary team
- Self-motivated, flexible person who can flourish in an office setting with colleagues as well as in a self- structured independent setting
- Ability to accept constructive feedback for continual improvement
- Ability to add to a team atmosphere where a team approach is highlighted and valued
- Thrives in a process based transactional work environment
- Quickly adapt to new technology
- Must stay abreast of all customer specific details, to ensure high quality customer service
- Accept additional assignments willingly
- Reports to Corporate Delegation and Auditing Department Lead
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.
- Valid nursing license in good standing
- Certified Auditor (Landmark will do the education and certification)
- Ability to obtain license in the states for which you are assigned as required
- Experience in case management, assessments and care planning
- Knowledge of CCM
- General knowledge of Audit functions, purpose and reporting
- Knowledge and/or experience with Regulatory Audits
- RN with BSN
- Certified CCM
- 2+ years of clinical audit experience
- IRR (inter-rater reliability) experience
- NCQA knowledge and experience
- Quality Assurance/Auditing experience
- CCM/Delegation auditor experience
- HEDIS familiarity
- Basic computer knowledge such as Word and Excel
- Demonstrated solid administrative, clerical and organizational skills
- Demonstrated excellent customer service and follow-up skills
- Proven solid attention to detail
- Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
- Regular requirement to sit; use hands to touch, handle or feel
- Regular requirement to talk and listen
- Occasional requirement to stand; walk and reach with hands and arms
- Occasional requirement to lift and/or move up to 10 pounds
- Vision abilities include close vision, peripheral vision, depth perception and ability to adjust focus
- Initial high frequency visits to patient residences followed by as needed visits during market implementations
- Will require regular travel to patient residences and non-home-based market offices
- Noise level is usually moderate
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)
Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $66,100 to $118,300. The salary range for Connecticut / Nevada residents is $72,800 to $129,900. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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.